• News
  • The enemy within

The enemy within

David Learmount/LONDON Ramon Lopez/WASHINGTON DC

Julian Moxon/PARIS Paul Phelan/CAIRNS

DESPITE BEING ABLE to report a particularly safe 1995, director of US Army aviation safety Brig Gen Thomas Konitzer sees a need for caution. "The force reduction has increased the workload for Army aviators. Not only have missions increased, turnover has increased, leadership inexperience has increased, and I sense that frustrations in the field are increasing. All the warning signs are out there," he says.

It seems to take the USA to spell out truths which others are reluctant to explore even as possibilities. The USA, operating by far the world's largest military-aviation forces, and being one of the few remaining nations to operate aircraft carriers, is the world's primary source of military-aviation experience in all fields, especially in the safety arena.

On the other side of the Atlantic, despite reporting average safety performance during 1995, the Royal Air Force has started 1996 badly, with a rash of serious air accidents. Meanwhile, the French air force's office of flight safety sums up 1995 with sang-froid saying, "some years are worse than others", but it apparently feels that further analysis in public is not appropriate. The German air force has declined to comment on safety standards or programmes.

The US Navy has also made an inauspicious start to 1996, and is seriously concerned about a series of Grumman F-14 accidents for which a single cause is not immediately apparent. The Navy has decided however, to proceed with a flight- control upgrade for the type.

When pressed on the effects of having to respond to shifting political and military goals in a restless global theatre of operations, the RAF's Director of Flight Safety, Air Cdre Rick Peacock-Edwards, admits only that "...we have been through a lot of changes and it has been pretty difficult".

Peacock-Edwards, who is also chairman of the European Air Forces Flight Safety Committee, says with conviction: "What has struck me is how much commonality there is in [accidents/incidents] and the issues we are addressing. Human factors is the big issue."


Significant military commitment to Bosnia is one factor, which the US, French and UK forces have in common. Commitments in the Gulf created a similar situation. All three forces have lost aircraft and aircrew in both places. Meanwhile, the USA has faced Somalia and Haiti, and is standing apprehensively offshore watching the aggressive military posturing on the North/South Korea border and in the strait between China and Taiwan. Given that present US foreign policy seems to be to retain the nation's role as "world policeman", it seems incongruous that "downsizing" and "draw-down" are words repeated often in safety-related briefings by US senior officers.

On 13 February, 1996, an RAF British Aerospace Hawk trainer took off from RAF Valley in the UK, rolled rapidly immediately after take-off, and crashed, killing the pilot. Initial investigations revealed that the ailerons were still disconnected after maintenance checks. Despite the procedural breakdown in maintenance, the fault should have been, identified by the pilot and ground crew, during control checks before taxiing. A bulletin since circulated to crews stresses the existing drill, requiring checks of control-surface movement as well as full-and-free stick movement.

The Hawk accident was just one of the events which have caused the number of serious accidents involving UK military aircraft during the first three months of 1996 to equal the total for the whole of 1995. The situation is leading service chiefs to question whether this is just a statistical "spike", or if there is a common influence behind apparently unconnected accidents.

The political search for "the peace dividend" since the Cold War ended has seen the UK military confronted with studies to conduct and rationalisations to effect. The programmes have had names such as: "Options for change"; "Prospect studies"; "Front-line first"; "Civilianisation". Peacock-Edwards says that he has no reason to believe that civilianisation, which has been implemented most prominently in primary and basic flying-training, will cause a decline in standards or safety, but adds: "We have been extremely conscious of the need to maintain the military ethos" in the young officers. He says that one anomaly which has been thrown up by an inquiry into a training-aircraft accident (a Slingsby Firefly operated for the RAF by Hunting Aviation) is that the civilian instructor is not subject to air force law, while the student is.


On the other side of the globe, Wg Cdr John Thynne, Royal Australian Air Force (RAAF) deputy director of flying safety, is rather more sceptical. He says that cuts in resources do not appear, so far, to be a threat to flight safety, but adds: "It's not that we don't have concerns. The change in culture towards civilian support-programmes and the re-focusing of the military to the sharp end means that we have to look very closely at safety implications."

The RAAF says, that it does not have to worry about "downsizing" (it is not doing it), but it is unsure about the effects of civilianisation of support services and is seriously concerned about the potential effect, on safety of losing a high proportion of its experienced aircrew and air-traffic-control (ATC) personnel, to an expanding air-transport industry. The problem is so severe that it is keeping numbers up by taking RAF and Canadian personnel on exchange, and trying to attract personnel made redundant by those two air forces.

The US Army's Konitzer, having voiced his uneasiness, takes the traditional serviceman's line, declaring: "We must continue to identify hazards, assess and manage the risks, make the right risk decisions, put controls in place, and supervise." Col William Bryan, the US Army Safety Center's director of programmes, is clear that the issue is a human factors one saying, "We have seen the enemy, and he is us."

Despite nervousness about the effect on safety, of increased pressures, the news for US military aviation is not all bad. Although it is frequently, a critic of the US Department of Defense, the US General Accounting Office (GAO) is relatively kind about the US military's performance in aviation safety.

The GAO, the investigative arm of Congress, noted in a report issued earlier this year that US military crashes have steadily declined over the past two decades, but that they still cost the Pentagon more than $1 billion a year.

GAO investigators have found that the number of major (Class A) accidents dropped from 309 in 1975 to 76 in 1995, and that fatalities declined from 285 to 85 over the same period. During the past 20 years, Class A mishaps per 100,000 flying hours have also been shown to have decreased from 4.3 to 1.5 (Class A mishaps are those which result in fatalities, destroy an aircraft or cost $1 million or more in repairs).

The report discusses accident-reduction programmes by the US military. It notes that the Army undertook a study to determine the causes of an increase in Bell OH-58 scout-helicopter accidents. The resulting report observed that a disproportionate number of such accidents had taken place at night and involved human error, so the army developed a series of profiles for predicting whether a mission was low, medium or high risk. This original study spawned a system to assess risk before each OH-58 night mission, as well as guidance for reducing the risk to acceptable levels.

Following introduction of the risk-profiling programme, the "mishap rate" declined, and the Army plans to expand the use of the risk-management system to include other aircraft. The GAO report notes that now the US Air Force and USN are also developing risk-management programmes of their own.

Konitzer calls fiscal year 1995 "a banner year" for Army aviation. During the period, aviation units suffered only ten Class A accidents and a flight accident rate of 0.83 per 100,000 flying hours. In comparison, the Class A mishap rate was 1.64 in fiscal year 1994 and 1.57 (22 accidents) in 1992. For the current fiscal year, which began on 1 October 1995, the Army has suffered five Class A accidents - a mishap rate to date of 0.94. There have been seven fatalities and three aircraft destroyed. In several cases, the accidents could have been avoided "...had proper risk-management procedures been used", in Bryan's opinion.

A material-related fatal accident involved a two-seat Bell AH-1F gun ship, and Bryan sees a troubling trend for the aging fleet. "The Cobras will give us problems, and we must seriously think about retiring them," he believes.

The GAO report raises questions about the independence of the US military accident-investigation boards. For example, until recently, only the Army required safety-centre investigators to be voting board members.

The USAF recently moved to enhance the independence of its investigations. Now, an Air Force Safety Center official is a voting member in all Class A flight-mishap probes. Previously, the centre provided a non-voting "process expert" to a board.

The change was one of 12 recommended by an independent review of the USAF's aviation-mishap prevention programme. Although concluding that the overall programme was valid, the panel said that improvements could be made.

The dozen recommendations, including the merger of the USAF's safety office at the Pentagon with the Safety Center, based at Kirtland AFB, New Mexico, were put into effect on 1 October 1995. Brig Gen Orin Godsey continues as the USAF's safety chief, but is now director of the Center.

Godsey says that some of the recommendations are overdue: "In bureaucratic organisations, changes are sometimes hard to bring into being from within," he says, adding: "Every time the USAF convenes an accident-investigation board, we have failed from a mishap-prevention standpoint."

Despite suffering, 18 Class A accidents between January and June 1995 (ten in May and June alone), the USAF ended FY1995 losing fewer aircraft than in any other year in its history. In all, 53 people died in USAF crashes in 1995, the seventh lowest total ever. One of the 29 fatal crashes cost more lives than any single accident since the Vietnam War, however.

The USAF's Class A mishaps total for FY1995 was 32, with aircraft destroyed in 29 of the cases. The overall mishap rate was 1.4 per 100,000 flying hours, the third lowest. The major accident rate for fighter and attack aircraft was 2.59 mishaps, however. The ten-year Class A average is 1.5 mishaps. Half of the 32 accidents were caused by operational factors, including control loss and mid-air collisions. The rest were, for the most part, caused by engine failure, the USAF says.


The worst disaster took place in September, when a Boeing E-3B surveillance aircraft crashed at Elmendorf AFB, Alaska, during take-off for a training mission. All 24 people aboard were killed when the four-engined aircraft (effectively a military 707) crashed in heavy woods 3.5km (2nm) beyond the air base, the first and only E-3 loss since the aircraft was introduced in 1977. The remains of a dozen geese were found at the end of the runway and the formal investigation said that bird ingestion knocked out the E-3B's two left engines, forcing the aircraft into a slow left roll from which it never recovered.

Geese were, spotted by controllers, just before the take off roll, but the flight crew was not notified. That omission, and the base's failure to keep geese from roosting on the runway infield, contributed to the accident, says the official report.

Bird strikes are a universal problem, which is costly and dangerous. The RAF is building a European database of bird strike patterns and probability, based on bird-migration information as well as on incident data. The level of bird strike risk can now form part of a pre-flight briefing, says Peacock-Edwards.

In 1982, the USAF achieved no better than a 2.5 mishap rate, but, strangely, in the year of the Gulf War, 1991, it had dipped to 1.1. In the three years following the war, the rates rose again to 1.6, 1.3 and 1.5.

Godsey explains that, during the Gulf War, fighters were used primarily for surveillance and to attack ground targets. Upon returning home, the aircrew had lost their edge in performing their primary air-to-air mission, and, therefore, the accident rate moved up. An intensive retraining programme was instituted, which reduced the aircraft losses.

Other measures put in place by the USAF, include crew-resource management (CRM) and a leadership safety initiative in which commanders are made accountable for accidents. Godsey says that an operational-risk-management (ORM) programme based on the US Army project will be in place by 31 October 1996. He predicts that ORM and CRM "...will pay big dividends".


The public's scrutiny has been focused on the safety record of USN and Marine Corps tactical aircraft. Earlier this year, the Navy ordered a three-day halt to flights of F-14s after three were lost within a month. The crashes prompted the USN to proceed with the upgrade to the F-14 flight-control system. GEC-Marconi Avionics digital flight-control computers, designed to prevent flat spins and improve carrier-approach handling qualities, are now installed.

The USMC had a two-day "stand-down" of its own in late March after losing six aircraft in a six-week period. Five crewmen had been killed in fixed-wing and helicopter crashes. The aircraft grounding allowed aviators and ground personnel to conduct a review of all maintenance and operational procedures and policies, but the USMC says that there was no immediately apparent common thread in the recent losses.

Commander Australian Naval Air Capt Eames says that safety philosophy now concerns itself with "aviation safety" rather than "flight safety". Eames explains: "That term includes the ships, and everyone involved in aviation, rather than just wheels-off to wheels-on - everything from the education process to the reporting, closing the loops on actions."

Widening the safety arena seems to be a progressively more common policy. In the RAF, Peacock-Edwards declares that the CRM programme "...has moved apace", and that, by the end of 1996, all its aircrew will have done a CRM foundation course.

The RAAF's Thynne says: "A good 1995 has allowed the RAAF to concentrate more of its improvement efforts on support services...1995 was an accident-free year for the RAAF. That has allowed the service's safety practitioners more time to focus on another safety area - ATC and related services."

This ATC focus is not arbitrary, Thynne points out. "Manning of ATC units is a concern," he says, adding: "We'd noted an increase in controller-related incidents, including some involving civil aircraft, which prompted us to take pro-active action. We've instituted, a system of full audits of air traffic units at all our bases, which began in Darwin in December 1994 and is almost complete.

"When we conduct audits, we take Airservices Australia and Bureau of Air Safety Investigation staff with us to make sure it's an holistic view of all the airspace around our bases rather than just the military airspace, and those reviews have been very successful."

To date, air-traffic audits have produced 141 recommendations, of which 111 have been accepted. Of those, 94 have already been implemented, says the RAAF. Thynne notes that all flying units have also subjected to audit by the RAF's Peacock-Edwards. "He made recommendations, many of which were things we already wanted to do and wished to have happened anyway," Thynne says.

He emphasises all forms of information as being vital parts of all the programmes being enacted: information gathering, analysis and dissemination, with incident reporting being encouraged. "We instituted a confidential reporting system in March last year called the CONFIR [confidential incident report]," he reveals. In the meantime, another information theme has been initiated. Thynne says: "We have a theme this year of looking back at past accidents, so we stir the corporate memory again."


The RAAF looks set to be stable in size, so morale problems relating to insecurity, are not seen as an issue. Loss of experienced personnel who elect to leave is a major worry, however. Thynne says that a recent review may be "...looking to increase if not the status, at least the earning power of people like pilots or engineers who are in demand in civilian life". He puts ATC personnel in the same category.

"My biggest concerns are both manpower-related," continues Thynne. "One is the drain on our air-traffic system, with people moving to Airservices Australia at a significant rate. We're also losing a substantial number of pilots to Saudi Arabia for their [Pilatus] PC-9 and Hawk programmes, and to Qantas, which has a significant expansion in pilot numbers under way." The figures show that 33 pilots left in 1991/2, but that increased to 88 in 1995. The respective figures for ATC personnel were 16 to 53.

"That's impacting on our experienced middle-level people," Thynne emphasises. "It's not something's just the size of the problem that is the concern." He explains that the losses are also tending to leave the RAAF short of middle management, because most aircrew leave as experienced flight lieutenants or squadron leaders with some two to three flying tours and 2,000-3,000h flying. The fact that aircrew of the same age 20 years ago would have had about double the flying time in their log books is a worry in itself, says Thynne.

Meanwhile, Airservices Australia is seeking about 400 controllers over about four years. The RAAF has only about 290 ATC positions and a substantial proportion of controllers is likely to leave, so the service has instituted a $A70,000 ($54,000) taxed bonus for retention of controllers, but that is only recent and its effects are not yet visible.

The RAAF has re-pitched its annual pilot-recruiting target from 45 to 55, and is using "loan-service" flying instructors from the Canadian Forces and the RAF. It is also taking advantage of the reduction in those forces to recruit experienced pilots.

Those major air forces and air arms, which declare their incident figures and safety programmes seem to have in common a long-term trend towards fewer accidents and lower accident rates. They also seem to have in common, however, a nervousness about what the future is going to demand of them, and the effects on safety of a combined increase in individual workload and tighter budget constraints.