Tuesday, June 26, 2007

Absorbing the Hard Lessons

Thirteen years ago this month, an Air Force B-52 crashed while rehearsing for an air show at Fairchild AFB, near Spokane, Washington. All four crew members aboard the aircraft were killed when the bomber banked too steeply at low altitude and stalled. A photographer standing on the flightline captured the last, desperate moments of the aircraft and its crew.

The ill-fated B-52, seconds before the crash. The small object just above the aircraft is the co-pilot's ejection hatch. Unfortunately, the seat failed to clear the jet before impact and he was killed, along with the other crew members

The Fairchild crash was a tragedy on many levels. Not only did it claim the life of four experienced crew members, it came at a particularly bad moment for the base and the wider community. Four days earlier, a Fairchild airman, about to be discharged for a severe psychiatric disorder, went on a rampage at the base hospital, killing five people before being fatally wounded by a responding security policeman.

A detailed investigation of the B-52 crash only compounded the anguish. Investigators learned that the mishap could have been easily prevented, had leadership of Fairchild's 92nd Bomb Wing disciplined the pilot at the controls of the doomed jet, Lt Col Arthur "Bud" Holland. A review of Holland's high-profile missions at Fairchild revealed a long history of disregarding safety and technical order data, which set maneuvering limitations for all types of aircraft, including the eight-engine heavy bomber.

Much has been written about the Fairchild crash, most the detailed study prepared by then-Air Force Major Tony Kern. His "Darker Shades of Blue: A Case Study of Failed Leadership" published by Neil Krey's CRM (Cockpit Resource Management) Developers, remains the definitive account of the organizational complacency and complete lack of accountability that led to the disaster at Fairchild.

Kern's study paints a picture of a supremely-confident aviator (Lt Col Holland), whose obvious skills as a "stick and rudder" pilot obliterated his judgment as an airman. On at least six separate occasions before the fatal crash [emphasis added], Holland flew his B-52 at altitudes, bank and pitch angles that were in clear violation of Air Force regulations. During one of those episodes, his bomber barely cleared a ridgeline at a bombing range, where a DoD-authorized crew was filming.

Another B-52 piloted by Lt Col Holland barely clears a ridgeline at the Yakima, Washington bombing range in March 1992. Fearing for their safety, the film crew ceased operations and took cover. On a subsequent pass, Holland reportedly cleared the ridge by only three feet, grossly violating safety "minimums" for altitude and clearance (H/T: Wikipedia).

On another occasion--the 1993 Fairchild base airshow---Lt Col Holland flew a profile that clearly exceeded safety and technical order data. At one point, according to a crew member observing from the ground, Holland put his "Buff" into a near-vertical, pitch-up maneuver, putting the bomber dangerously close to stalling and crashing.

As Kern reminds us, the chain of complicity didn't end with the rogue pilot. At air shows, change-of-command ceremonies and similar events, he executed illegal maneuvers in front of senior officers, but was never formally sanctioned for his conduct. Holland served under at least four different wing commanders during his time at Fairchild, and under multiple Operations Group commanders. Kern--who based his examination on the transcripts and files of Air Force investigators--found no record of any senior leader (at the O-6 or flag level) attempting to discipline Holland, or ground him from flying.

And the rush toward disaster continued. In planning sessions for the 1994 air show, Lt Col Holland briefed profiles that were outside prescribed limits. The Wing Commander corrected him, but when Holland performed out-of-limits turns and pitch-up during an initial practice session--in clear defiance of the wing commander's directive--nothing happened. Holland remained as aircraft commander, and the ill-fated bomber, callsign Czar 52, took off for its final practice mission on the morning of June 24, 1994.

The man in the right seat that day was another highly-experienced B-52 pilot, Lt Col Mark McGeehan. In the investigation that followed, Lt Col McGeehan emerged as one of the few heroes of the tragic saga. As commander of the 325th Bombardment Squadron at Fairchild (the B-52 unit), McGeehan listened to complaints about Holland's unsafe practices from his pilots and navigators. Lt Col McGeehan elevated those concerns to his superiors, who failed to act.

McGeehan also decided that he would not endanger the lives of his younger crew members by putting them in a Buff with Holland at the controls. Instead, Lt Col McGeehan and his operations officer, Lt Col Ken Huston, penciled themselves onto the schedule as Holland's crew. They were joined by the Wing Vice-Commander, Colonel Robert Wolff, who was added as a safety observer. Czar 52 crashed as the pilot--undoubtedly Holland--tried to execute an extremely tight turn around the base control tower at low altitude.

More than a decade later, we believe the Fairchild tragedy still offers important lessons for the intelligence community. Many of the traits evident in the 92nd Bomb Wing--complacency, a lack of accountability, and a refusal to follow existing regulations--are evident within intelligence organizations.

Consider the "leak culture" that proliferates within the community. As we've noted in the past, there have been over 500 deliberate disclosures of classified information since 1995--and not a single, successful prosecution. Earlier this year, the FBI complained that intelligence agencies remain uncooperative in the effort to ferret out leakers.
That speaks volumes about a profession that has become increasingly politicized, populated by an active minority that is willing to advance its own aims, with little regard for potential consequences. An assessment of the afore-mentioned leaks concluded that the disclosures have, collectively, caused serious damage to our national security, yet the incestuous relationship between leakers and the press continues to flourish.

As for accountability, we are still stunned that not a single, senior intelligence official lost his or her job because of the failures surrounding 9-11 and the Iraq WMD issue. That sends a clear message to senior leaders--as well as the rank-and-file--that it's okay to make the same mistakes, over and over again. With minimal standards of accountability, it's little wonder that the hide-bound intelligence bureaucracy refuses to change and adapt.

We can only imagine the "first impressions" of the thousands of new analysts who have joined the community over the past six years. Sadly, many of them will become frustrated by the problems that continue to plague our intel organizations and move on to greener pastures, leaving the next generation of politicians and bureaucrats to perpetuate the status quo. Despite Congressional investigations and the work of two "blue ribbon" commissions, the culture that helped produce massive intelligence failures in the recent past just keeps puttering along.

Ironically, the Air Force--or at least, the service's pilots and aircrew members--seem to have learned from the Fairchild tragedy. The crash of Czar 52 remains one of the most-studied and analyzed mishaps in aviation history. Kern's analysis forms the foundation of a case study taught at the Air War College, and the incident is widely used by civilian and military aviation instructors in training new pilots and crew members.

By comparison, we remain unconvinced that the intelligence community has internalized the "hard lessons" of its recent failures. Comparing conditions across a vast bureaucracy to the factors behind a single B-52 crash may represent an inexact analogy, but (from our perspective), many of the cultural trends observed in the 92nd Bomb Wing in 1994 are also evident within today's intelligence community.

Like that Air Force bomb unit, the intelligence profession has paid dearly for its complacency, its disregard for protecting nation's secrets, and its refusal to hold members accountable. These problems have festered under successive administrations (Democrat and Republican), and under a parade of senior officials that are supposedly our "best and brightest." As with the leadership of the 92nd Bomb Wing in 1999, our intelligence leaders are either oblivious to the problem, or (perhaps more accurately), they find the culture resistant to change, and simply give up after an initial flurry of effort. Whatever the reason, these conditions still persist in our intelligence agencies, and the potential cost of these problems may be measured in thousands of dead Americans, not the loss of a single bomber and four crew members.


Unknown said...

you know i read your blog almost daily and really enjoy your article - for the most part - however i have to respectfully disagree with the article about the B52 pilot and your criticisms of the system in place.

I dont want to debate this endlessly and I am quite certain my opinions here will not alter your views on this pilot, but nonetheless i am driven to post this comment.

my main point of contention with your article is the blame you place on the system and his superiors for the accident happening.

i believe that in certain highly trained areas of the military forces there is a NEED for less discipline, for the ability for these highly trained individuals to experiment and get the job done.

special forces, pilots, and other specifically trained individuals should be given much more leeway - it is afterall a reward for their dedication to the discipline that affords them the opportunity to carry out missions as they see fit, or grow a beard, or not salute you, or operate a little outside safety boundaries.

this pilot was a careless pilot but probably a very good pilot. there was no amount of disciplining that would stop him from flying the aircraft to its limits.

the saddest thing is the loss of 3 other lives that probably didnt appreciate his piloting on this day - and also the loss of the multimillion dollar aircraft.

either way, i do not believe that they should discipline pilots but rather guide them.

no blame.

Unknown said...

David--Thanks for your comments. In the Air Force, we had a saying, "Flexibility is the Key to Airpower," which implies a certain freedom to improvise and adapt--the qualities you alude to.

But there have to be limits in those areas, including the restrictions imposed by physics. In each of the examples uncovered by investigators (and highlighted in the Kern study), Lt Col Holland put his aircraft on the absolute edge of the envelope, taking unnecessary risks. At at airshow in Canada, he put the Buff into a near-vertical climb at low altitude--some it was not designed to do. He somehow pulled it out, but the crew reported that airspeed dropped to 70 kits during the maneuver, and they felt the aircraft shudder as it began to stall.

Maneuvering your aircraft to save your life in combat is one thing--I know an AC-130 gunship pilot who Over-G'ed his aircraft over Bosnia, because he was locked up by a Serb SA-6. It took months--and a lot of dollars--to make the AC-130 airworthy again. But the aircraft commander made the right call. In a peacetime, "airshow" environment, Lt Col Holland repeatedly made the wrong call, and ultimately, the crew of Czar 52 paid for it with their lives.
The fact that he violated safety rules under FOUR wing commanders is even more telling, and evidence of the poisonous culture that existed at Fairchild.

Finally, in the words of Harry Callaghan, a "man's gotta know his limitations," and that includes his equipment. I might want to rent a Cessna at the base Aero Club and attempt an outside loop, but in all likelihood, the wings are gonna fall off in the attempt, and I'll be a smokin' hole in the ground. Similarly, the commanders at Fairchild repeatedly allowed Lt Col Holland attempt maneuvers that violated safety and tech data, setting the stage for the data that ensued.

Unknown said...

Last line of my comment, I meant "disaster," not data.

johca said...

"special forces, pilots, and other specifically trained individuals should be given much more leeway - it is after all a reward for their dedication to the discipline that affords them the opportunity to carry out missions as they see fit, or grow a beard, or not salute you, or operate a little outside safety boundaries."

There is a time and place to operate outside of safety boundaries, unfortunately such decision is as likely to result in failure as it is success and decision to do often results from being in extraordinarily strange situations and circumstances that if you don't attempt to do--failure is certain and if you do and succeed you're the hero.

The distinction that distinguishes the fatal crash being discussed is the pilot-in-command decided to exceed safety limits when there was no desperate or extraordinary need to enter into the specific unsafe flight profile to begin with. The problem is not one bad error in judgment but a sustained pattern of to willing recklessness for purpose of showing off rather than accomplishing a military mission. The greater culpability is such sustained pattern of recklessness for self pleasure of being the great showman was ignored by the chain of command.

Ralph Hitchens said...

Absolutely astounding! How a guy like that got to be chief of stan/eval is beyond me. Thanks for posting this -- somehow, I missed the story when it happened.

jimbowe said...

I was at an airshow at Buckley AFB in the late '80s with some friends and had just come off a two and a half year tour as the Thunderbird photographer. (I have seen too many airshows to count.) There was a B-52 there that did an incredible low-level, high-speed pass with a pull up to almost vertical. I watched it climb and slow until it seemed that it was going to tail slide. I actually grabbed the person next to me when at what seemed the last possible moment, the aircraft pushed over at the top and began gathering air speed again.

When the crash at Fairchild occurred, my thoughts went back to that B-52 at Buckley and to this day I wonder if it was the same pilot. I can still see that climb out as clear as day in my mind, it scared the heck out of me.

billmill said...

I saw the same thing for years in my 21-year career. There were always a certain group of pilots that could do just about anything behavior wise and get away with. If any of my fellow SNCO’s had acted in such a manner we would have been hammered flat. Now having said this I have also seen certain SNCO’s come up DUI’s and other breaches of behavior and manage to avoid sever penalty.
One of the worst cover-ups I saw that didn’t get anyone killed was on an F-15E model at RAFL in the late 90’s. At the time certain high AOA maneuvers were flight restricted, this crew did one and almost lost the jet, in the recovery they pilot managed to due an over “G” that maxed out the chart. They compounded the error by failing to declare an IFE and landed without a word being said. The crew chief noticed that the ASP for Over G was latched and that’s when things got interesting. During the investigation it was discovered that the jet suffered a mass item maximum over g event. Both engines were shot and off to depot. Both wings were done and were replaced by our contract depot field team. All told parts and labor well over a million (Class A) but it never saw the light of day. Both crewmembers received minor sit-downs and the costs were never accurately reported. People that are surprised by the behavior that was discovered after the fatal crash at Fairchild simply has not been in or around the Air Force long enough.

Brian H said...

Pilots like that are just f'ing crackheads. Literally. The brain pumps out joyjuices that make street shit look like sugarwater, and are immensely addictive. The only way to get them pumping is with more and more of what got you there.

Serious detox and addiction treatment is what they need.

J.Chaguaceda said...

Logig is logic no? A B-52 is not there to do stunts and fly in an dearly foolisch way. It is a warplane to fly very high and horizontal! That Pilot had the wrong plane to do his stuff! Some people can`t think and act right.
It`s very tragic that so many lost ther life, for that crasy fool.

J.Chaguaceda said...

Logig is logic no? A B-52 is not there to do stunts and fly in an dearly foolisch way. It is a warplane to fly very high and horizontal! That Pilot had the wrong plane to do his stuff! Some people can`t think and act right.
It`s very tragic that so many lost ther life, for that crasy fool.sincerly José Chaguaceda

Unknown said...

Why this plane was named Czar 52? To strike the heart of URSS if the ICBMs were neutralized, right? Ok, then Holland Kamikaze was a special weapon of nuclear deterrence. This make him a hero.

Jerry said...

Lt Col. Mark McGeehan (the copilot) and I attended Air Command and Staff College together. There is no doubt in my mind that he was destined to be a General Officer, until a B.S. air show demonstration of a B-52 doing acrobatics took his life.

He did the right thing though -- he reported it to his superiors and tried to get the pilot pulled. When that failed, he did what most military leaders will do -- he didn't ask any of his subordinates to do what he wouldn't do. So he penciled himself in.

Someone's ego got in the way and some good people got killed. Was it the ego of the pilot -- or the Commander who refused to pull the pilot from the air show -- since ACC was taking all of the cream joint commmand positions I put the blame on the senior leadership. They endorsed the reckless flying.

Jerry Sexton, Lt Col, USAF (retired)

DrTracy said...

Having spent a number of year in the USAF, I have seen the type of person Bud Holland was. They develop what is sometimes seen in physicians such as myself(I wasn't a physician in the USAF). It is the "god complex". It leads them to tread on the thin line of disaster. But, in treading on that thin line, inevitably you will fall off the edge. Physicians often fall into this trap. But to avoid this, you must discard the hubris which comes with your title and continually assess the sensibility of what you are doing. As my Physics professor in college said, "Before you do anything in life, ask yourself Is this reasonable?" If you can do this with full self awareness and humility, you can prevent disaster. It is in my opinion, the one thing that enables me to say with pride that in over 20 years of practicing medicine, I have never been sued for malpractice. In those inevitable moments when I must tread on a thin line that separates me(and the patient!)from disaster(never, ever by choice!)I am continually assessing whether or not my individual actions are sensible. Those with the "god complex" like Bud Holland can never separate the legend from the reality. Thus, he and 3 others wound up as a pile of ashes.

Bill Major said...

Lt Col Mark McGeehan was a classmate, mentor and friend. He was an honorable and humble Air Force Academy cadet, officer, husband and father. I miss him dearly and grieve for his wife and children. Bill Major

DrTracy said...

I have read and reread this story and watched the video many times. I am in the process of reading Tony Kern's book "Darker Shades of Blue-The Rogue Pilot" and am fascinated by it. Tony said in the book and I agree, that there are rogues in every profession, including mine. He cited an example of a rogue doctor(medical). I have been in the USAF and saw many examples of rogues. Maybe there is a little rogue in all of us screaming to get out. But good sense and a sense of self preservation prevents us from letting it out like LtCol Holland. And LtCol McGeehan was a hero. If only he could have wrestled the controls away from Holland in those last minutes. In his book, LtCol Kern said that LtCol Holland told someone the day before the crash(I almost referred to it as an accident-it wasn't)something to the effect "The Air Force is really stupid, allowing me to fly my last flight in an airplane at the Air Show". Having said that, it was obvious what his intent was and it is a good thing the crash occurred the day before. Otherwise, there may have been hundreds of deaths instead of "just" four. In my training as a medical doctor, I saw an example of a rogue doctor who showed, one night when I was on call, roguish behavior, delivering a baby in a highly inappropriate manner. In the long run it turned out OK, but it might not have done so.

Unknown said...

Bull. This article is spot on. Three gave their lives to save many from one HOTSOT who should have been reduced to desk duty. I'm furious Shouldnt discipline pilots? Smh