Monday, January 28, 2008

What Happened at Minot--an In From the Cold Special Report

Part II—Fixing a Broken Wing

By Nathan Hale

Author’s note: Part I of this series explored leadership mistakes that contributed to last year’s nuclear mishap at Minot AFB, North Dakota. In today’s second installment, we examine efforts to restore the nuclear mission of Minot’s 5th Bomb Wing, and prevent similar incidents from happening in the future.

It began as a routine, late-summer day at Minot AFB, North Dakota. Giant, eight-engine B-52 bombers, older than most of the pilots that flew them, lumbered aloft at regular intervals, heading out on scheduled training missions.

On the base flight line, maintenance crews worked on the aging jets, which rolled off the Boeing assembly line in the early 1960s. By some estimates, each hour of flying time generated $1200 in maintenance costs, making the “Buff” one of the most expensive aircraft in the Air Force inventory.

But no other bomber could match the payload of the B-52, and the service planned to keep them operational for another 30 years. That meant a bright future for Minot’s 5th Bomb Wing, one of only two B-52 units remaining in the Air Force.

On the morning of August 29, 2007, most of the Buffs parked at Minot bore the familiar “MT” designation on their tails, identifying them as part of the 5th BMW. But one of the bombers carried a different set of letters. The aircraft's “LA” markings indicated that it belonged to the 2nd Bomb Wing, stationed at Barksdale AFB, Louisiana.

The Barksdale bomber was on a ferry mission. Later that day, ground crews from Minot would load 12 advanced cruise missiles (ACMs) beneath the bomber’s wings, the next step in their retirement from the U.S. nuclear arsenal. With their nuclear warheads removed, the missiles would be flown to Barksdale for decommissioning. Personnel from the two bases had already completed five ferry missions; today would be number six.

Around 8 a.m. (local time), maintenance crews began removing the missiles from their storage bunker. By nine-thirty, the wing’s munitions control center approved their loading onto the B-52. The mounting operation proceeded at a leisurely pace, concluding eight hours later. With the missiles in place, the bomber sat on the ramp until the next morning, awaiting the return flight to Barksdale.

According to Air Force records, the B-52 departed Minot at 8:40 a.m., passing over portions of seven states before arriving at Barksdale three hours later. As the bomber crew headed off for debrief—and the start of a four-day weekend—the bomber and its missiles remained parked on the ramp for another ten hours. Maintenance crews weren’t scheduled to remove the missiles until later that night.

Around 8:30 p.m., a member of the load team noticed something unusual about the missiles and alerted a supervisor. Ninety minutes later, the airman’s suspicions were confirmed. Six of the missiles still had their nuclear warheads installed. Security was alerted and word of the incident raced up the chain of command, all the way to Defense Secretary Robert Gates, and President George W. Bush.

The nation’s worst nuclear mishap in 40 years had just occurred.

Fallout from the incident was both immediate and long-lasting. As the Air Force launched multiple probes into the matter, it fired the 5th BMW commander, the maintenance group commander and the commander of the unit’s munitions maintenance squadron, citing “an erosion of adherence to weapons-handling standards.” The Operations Group Commander of Barksdale’s 2nd Bomb Wing (which “owned” the aircraft and crew involved in the incident) lost his job as well.

But the list of firings and disciplinary action didn’t stop there. The Chief Master Sergeant in charge of the wing’s special weapons flight was dismissed and reassigned; four of her top subordinates were demoted and transferred to other jobs at Minot. Scores of lower-ranking enlisted personnel received lesser forms of non-judicial punishment and lost their certification to work with nuclear weapons.

The mishap left the wing—and the Air Force—in a quandary. With the decertification of so many key personnel, the 5th BMW lost its qualification to conduct nuclear operations. Regaining that status meant retraining (and recertifying) more than 50 personnel to the exacting standards required for nuclear weapons work. Wing personnel also had to pass three demanding inspections, verifying their ability to safely store, maintain, safeguard, transport and, if necessary, employ nuclear systems.

And the timeline for meeting those goals was compressed, to say the least. Shortly after arriving at Minot, the new 5th BMW Commander, Colonel Joel Westa, announced a goal of completing recertification by mid-February. The first hurdle in that process would be an Initial Nuclear Surety Inspection (INSI), scheduled for mid-December, and conducted by the Air Combat Command Inspector General (IG) team.

More than 200 inspectors participated in the evaluation, which examined personnel, procedures and paperwork. But when the results were revealed on 19 December, the headline took some observers by surprise. Both Col Westa and the Wing’s Chief of Public Affairs, Major Laurie Arellano, announced that the unit would “be given more time to prepare” for the follow-on nuclear surety inspection, originally scheduled for the following month.

“The inspectors have determined we need more time to make the necessary changes and allow us to accomplish long-term solutions, including filling critical leadership billets that are currently vacant,” Arellano told local media outlets. “We are thankful we can take the time needed rather than being forced into an artificial timeline, so the NSI will be postponed until the wing and the command are confident the right people and processes are in place.”

“Getting this mission perfected and recertified is the No. 1 priority of the command and the wing,” she continued. “We are taking a holistic look at the wing. That includes ensuring that we fill leadership positions that are currently vacant and build the teams necessary, with the leadership in place to oversee the long-term changes.”

What Major Arellano (and her boss) didn’t disclose was the underlying reason for Minot’s extension. Multiple sources tell In From the Cold that the 5th BMW received a grade of “Not Ready” on its INSI, the lowest possible rating. While not technically considered a failing grade, the score indicated that the wing was not ready for follow-on inspections, or recertification for its nuclear mission. Against that reality, the inspection team and the Air Force had no choice but to give the unit more time.

Reasons for the unit’s low grade—like the score itself—have not been publicly revealed. But reliable sources suggest that the “Not Ready” mark hinged on a single incident, which highlighted continuing problems with the bomb wing’s training and documentation efforts.

As a retired nuclear weapons expert described it: “During one of the nuclear weapons technical operations, a Bay Chief torqued a bolt. He torqued it correctly, but he was not formally certified to perform maintenance on nuclear weapons.”

That represented a red-letter violation. Training to work on nuclear weapons is very intensive. Maintenance personnel and other specialists first train on practice weapons before graduating to nuclear warheads. Individual training records have tasks identified and technicians must be started on the task and closed on the task. In the case of critical skills, also known as core tasks, another person must observe the specialist performing that function and initial the training records.

Nuclear technicians must also be cleared to perform certifiable tasks. That process requires that a Quality Assurance inspector observe the work, and pronounce the person certified. Select functions, such as transfer or transport of a nuclear warhead, require special certifications, above and beyond other training. Only after meeting all of those requirements can a technician become certified and perform maintenance on nuclear weapons.

Documentation of required training is extremely detailed, and mistakes do occur. But, as a former nuclear weapons NCO observed, simple documentation mistakes are not usually enough to drive a “Not Ready” rating. He suggests that the leadership void, created by the wave of firings and reassignments at Minot, and coupled with a faulty training program, led to the critical error.

“Since many experienced senior NCOs were removed from their jobs, this Bay Chief was probably moved up into his position. He was probably a Team Chief who was used to doing maintenance, so he didn’t think twice. Just picked up the torque wrench and tightened the bolt. In this case, the inspection team was being exceptionally picky, or the errors were egregious.”

The 5th Bomb Wing’s low score on the INSI—and the decision to delay subsequent inspections—raised new questions about the rush to recertify the unit. While it’s unclear who drove the original inspection schedule, the retired weapons NCO (who now works as a DoD consultant) believes wing leadership had the option of asking for more time, before the INSI.

“If Colonel Westa thought Minot needed more time to prepare, all he had to do was ask. He can get anything he wants right now. He didn’t ask. Tells me he didn’t realize they weren’t prepared.”

“I am surprised the new Wing Commander wasn’t more aware of the training problems,” the weapons expert continued. “He should have asked for more time. Implies to me that his officers and senior NCOs aren’t very sharp.”

The 5th Bomb Wing public affairs office did not respond to an e-mail request for comment on the INSI results, or efforts to recertify the wing.

While the ACC inspection team identified clear problems at Minot, the former weapons NCO suggested that the evaluation process is far from perfect. “Inspections are just snapshots in time,” he observed. And, more recently, “inspection time has been reduced as manning is cut. Inspections are no longer no-notice.”

He also suggested that cronyism has affected the evaluation process.

[Individuals] are chosen for those [inspector] slots based on friendship and who they know, or sometimes, because they are the only body available. Deficiencies have been dropped because the wing commander is a friend or someone vetted for the general. The saying in the nuclear career field is ‘incestuous.’ The guy you fail on an inspection today may be your boss next year.”

According to the retired weapons inspector, evaluations only provide a limited defense against “cowboy maintenance,” the tendency of personnel to cut corners or ignore required procedures in an effort to save time, or meet production quotas. He believes that cowboy maintainers were a key factor in the Minot mishap.

“My understanding is that the schedule [for decommissioning Advanced Cruise Missiles] changed. The pylon that was originally to have the warheads removed was never brought up to the Inspection and Maintenance Facility (IMF) to have the work done. The correct pylon was brought in and the warheads removed.

“At this point the schedule broke down. The enlisted folks who do the maintenance seemed to think they knew what the schedule was. They went to the structure and picked up the originally scheduled pylon even though the warheads had not been removed. No one checked to see if they were installed because they thought they knew what they were doing.”

While mistakes had already been made, the former nuclear weapons tech observes that the unauthorized transfer might still have been prevented.

“Munitions control could have saved the day by merely checking their database and ensuring that the pylon had the warheads removed. I was told by sources at Air Combat Command that the database showed the pylon still had the weapons installed, but the munitions controller they talked to said it ‘wasn’t his job’ to check that stuff.”

“To me, that is dereliction of duty. Failure to follow written instructions, because the Air Force instruction says that is his job.”

The retired NCO describes many of the “cowboys” as head-strong airmen who need constant supervision.

“You know what; there are 19 and 20-year-olds controlling the movements of these weapons. Some of them are just real egos. It takes strong NCOs to lean on them and make them pay attention to details. When you’re sitting in front of a computer screen, it just seems so easy. But this is not a new phenomenon. I worked with plenty of airmen when I was young who thought they knew it all,” he continued. “

It took NCOs to either baby sit and ensures they didn’t get into trouble, or humiliate the ego out of them. When the airmen start running things, no matter how smart or self-assured they are, there will be trouble.

As a case in point, he cited the Air Force’s last major nuclear weapons accident, which resulted in the destruction of a Titan II missile near Damascus, Arkansas in 1980. The mishap occurred after a socket fell down the silo, puncturing one of the missile’s fuel tanks. Explosive fumes eventually filled the structure and later ignited, creating a blast that destroyed the silo and missile, and tossed the Titan II’s nuclear warhead a distance of several hundred yards.

Investigators later blamed the disaster on maintenance technicians, who failed to tether tools being used in the silo--a step mandated by Air Force regulations.

In the wake of the Minot incident, the service has implemented tighter accountability procedures for nuclear weapons. The former nuclear inspector reports that some computer-generated tracking products have been replaced by custody documents that must be signed (and accounted for) by maintainers or aircrew personnel.

In one of the newest changes, custody documents are now required for weapons moving from storage to a maintenance facility. Previously, transfer of a weapon from a storage facility to maintenance was not considered a change of custody.

But will various Air Force investigations into the matter —and changes in procedures—be enough to prevent a similar mishap in the future? Sources contacted by In From the Cold have their doubts.

“It wouldn’t have mattered if a thousand more signatures were required,” muttered the retired senior NCO. “Once everyone accepted the pylon did not have nuclear warheads, then all the rules were out the window. Those new custody documents would have simply been more documentation that the handling crew would not have accomplished.”

He believes that available technology could help prevent similar events in the future, while cautioning that such systems are not a panacea. The former weapons inspector noted that radiological scanners could be put at the gates of weapons storage areas. “If a pylon rolls through that should be cold but shows up hot, then obviously something’s wrong. Will the Air Force spend the money? Probably not. There’s no money unless it comes from other projects.”

And, he believes the service has yet to learn the most elementary lesson from the Minot accident: with human beings “in the loop,” you cannot prevent all mistakes and the Air Force must be prepared to deal with the consequences.

“I’ve seen plenty of serious mistakes in my years of service that cost lots of money; thank God no one was hurt,” he recalled. “Is the incident isolated? That incident was isolated to Minot. But we used to joke that if you painted “trainer” on a real weapon, you could roll it out the WSA (weapons storage area) gate.”

“Is the fact that airmen violate safety and security rules isolated to Minot? No. And in my opinion, the investigation is all eyewash. They know what the cause was and they are spending hundreds of thousands of dollars to print paper that will go in a file and never be seen again.”

Coming Wednesday: a look at the potential long-term consequences of the Minot incident and what it could mean for the nation’s security.


Jeff Kouba said...

Thanks for the interesting series. I grew up in Minot, and have known both B-52 pilots and members of ground crews. The incident was a bit of shock.

Richard said...

Wow. I worked at the 5MMS from 1986 to 1990. There was something seriously wrong with Nuclear Surety that could have allowed this to happen. When I was there, simple mistakes in paperwork could result in a failed NSI and huge consequences. It just didn't happen. Looks like 5MMS (or whatever it is called now) totally dropped the ball on this one. I'm ashamed. I worked as OIC of ALMM branch (the group that would have been responsible for this) in 1989, so it would have been my former branch's job to make sure this kind of thing was unthinkable. Looks like I didn't leave much of a legacy behind.

Kevin said...

These are of course, nuclear weapons and extreme care should be taken in their handling. But so much of this seems overblown to me.

I worked as a process engineer in a semiconductor factory for several years, overseeing complex precision equipment which required a lot of complex maintenance. It seems overkill to fire so many of the officers and staff when the fault could likely have been narrowed down to one or two people. (This has been my experience in watching semiconductor fab maintenance screwups happen).

And the audit failing because an uncertified chief torqued a nut properly ... this starts sounding like how the school system, in the name of zero tolerance, degrades itself into zero intelligence.

I hope some common sense can be reintroduced. While it may be satisfying to wield a heavy axe and end careers indiscriminately, it can also result in the staff becoming unwilling to make ANY decision and take ANY risk. Better to follow the book and fly the plane into the ground than to wield any initiative and get one's neck cut off.

1charlie2 said...

I really can't say it's overblown. To those of us who worked with nuclear weapons, it's mind-blowing that adherence to procedures could get so lax as to result in the unauthorized transport of weapons.

There are very large numbers of overlapping responsibilities designed to prevent this sort of mishap. Including only allowing certified people to turn a wrench. These regulations are designed to be so finicky precisely to ensure that no one screw-up can result in a mishap. Because inadvertent mistakes will occur -- but another part of the safety net should catch it.

That's why when any of them -- even one -- is willfully ignored or subverted, the transgressor needs to get pounded on. Otherwise, over time everyone gets into a "don't sweat it" frame of mind.

And nuclear weapons turn up missing. Or airplanes fall out of the sky. Or patients die.

There are some career fields where perpetual attention to the smallest detail is vital.