Complete navigator to all 17 documents associated with this story. Click here.

Gen. Tom Hall's Resignation Letter

"We are headed for a disaster"

After 30 years in the Air Force, Brigadier General Joel "Tom" Hall decided to spill his guts. Hall--the Air Force safety director--used his seven-page retirement letter to call attention to "glaring" problems in the way the Air Force investigates accidents. Hall's letter depicts an Air Force safety system hampered by politics, meddling generals, stonewalling, conflicts of interest, and Orwellian "convoluted manipulation, distortion, and misuse of the English language." Hall also insists "the fix is straightforward" and he spells it out in remarkable candor. --BY

26 March, 1991

General Merrill A. McPeak, USAF

Chief of Staff

Washington DC 20330-1000

Dear General McPeak

I am deeply concerned with the continued effectiveness and legitimacy of the Air Force Safety program.  As I conclude my tenure as Director of Safety, I feel there are serious structural and integrity issues in the program as it exists today that must be fixed.  I'm firmly convinced the forthcoming 30 percent reduction in manpower in the FOA can be accomplished without negative impact if thoughtfully executed in concert with the fixes I'll discuss.  The merger of the Safety and Nuclear Surety Directorates and the move to Kirtland AFB in 1993, coupled with the creation of the Chief of Safety position reporting directly to your office can, if implemented wisely, be the most important improvement in the Air Force's safety effort in years.  These changes will present significant, though manageable, leadership challenges but, on the other hand, great opportunity.  However, I sincerely believe that as events and decisions are now occurring we are headed for a disaster.  Please read on.

There are many important subtleties and nuances to the foregoing, and in my effort to be brief, I do not mean to imply otherwise.

AIR FORCE SAFETY--STRUCTURAL AND INTEGRITY ISSUES

In the last year, 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 a mature and continuing politicization of the investigation process by having the operating command investigate its own mishaps and by using board president duty as an 0-6 screening test.  Even more troubling is the acceptance by senior leaders of a mishap investigation process which frequently obscures supervisory culpability; e.g., the USAF had 597 Class A mishaps from 1981 through 1990; of these, 418 (70 percent) had human error (human factor) causes.  Yet supervisory deficiency was cited in only 178 (42 percent) and training deficiency in only 84 (20 percent) of the mishaps involving human factor causes.  There are many nuances involved here; however, it all points to the same dysfunction in the safety program-- MAJCOM mishap investigations do quite well at identifying other command's causal role in a mishap; i.e., material failure.  However, the operating command, which is responsible for training and supervision, investigating its own mishaps does a rather shallow job at identifying its own role in the mishap as reflected by the above facts.

When you consider that, for the most part, all our skills (aviation, maintenance, etc.) are learned behavior, one should reasonably expect a human performance-error cause rate of 70 percent to trigger a significant injtitutional review, at some level of command, of how we are teaching our people to do their jobs, how we are evaluating their continuation training performance, or how our supervisory process is working.  It has not--and any effort to promote such a review runs into stone walls in every direction.  In my view, the fact that only 20 percent of the human error mishaps result in any comment about training and the supervisor's role in that training simply confirms that the investigative process has been politicized to the point of dysfunction.

There are other symptoms of trouble.  Tne Air Force's institutional integrity/character is undermined when the invesligating MAJCOM manipulates the classification of mishaps for the shallow purpose of falsely lowering its Class A mishap rate.  In 1989 and 1990, there were a total of three flyable aircraft that, as a direct result of a flying mishap, will never fly again . . . and these mishaps were reported as Class Bs.  Air Force and DOD classification guidelines are simple and easy to understand.  The Air Force guide, AFR 127-4, states a Class A mishap is one resulting in "(1) Total cost of $1,000,000 or more for property damage, or (2) a fatality, or permanent total disability, or (3) destruction of, or damage beyond economical repair to, an Air Force aircraft."

In the most fundamental terms, if you take an Air Force aircraft and cause $1,000,000 in property damage, or a fatality, or permanent total disability, or destroy it, or damace it beyond economical repair, you have had a Class A mishap.  Webster's New World Dictionary defines "economical" as "not wasting money, time ...." After confirming the MAJCOMs had decided against repairing the involved aircraft, HQ AFISC/SE recommended reclassifying these three mishaps from Class B to Class A mishaps.  SAF/IG concurred with this action which changed the Air Force's FY90 mishap rate from the "best ever" to a tie with our previous best year.  One MAJCOM/CC formally protested the decision stating, "It made no sense to spend some $850,000 to repair this asset even considering that this would have been clearly economical when you consider the aircraft value of over $18M." This argument is internally contradictory.

Such convoluted manipulation, distortion, and misuse of the English language for a self serving, image-building illusion astounds and disappoints me.  Many others, particularly the young who have been taught to expect a far higher standard from senior officers, share that reaction. Your call for absolute integritv in all we do falls on skeptical, if not disbelieving, ears in view of gross politicization and manipulation of the mishap investigation and reporting process.  The current mishap investigation and reporting process has evolved in such a way that operating commands are able to obscure culpability, cause, and resource accountability.  And even though the occurrences are not frequent, the effect is the same--a noneffective mishap investigation, reporting, and prevention program discredited by a few breaches of integrity.  The fix is straightforward.

1. Ensure independent, thorough, candid mishap investigation by placing the responsibility for the investigation under AF/SE.  The board president and investigating officer would come from the safety Field Operating Agency. The operating command would provide the remaining board members and support.

2. The AF/SE board president would present the post mishap investigation briefing to the operating MAJCOM, to other MAJCOMs assigned corrective action, and to you and the Air Staff in a condensed form.

3. Each board would be governed by experienced, dedicated investigators as opposed to the current "it's your turn in the barrel" approach.

4. After publishing the formal written report, the Air Force Safety Center would receive, consider, and incorporate MAJCOM comments in the Air Force Letter of Final Evaluation. (This in itself would cut months off the current process and be far more responsive to mishap prevention efforts.)

5. Since the mishap investigation process as broadly outlined above would ultimately belong to the Chief of Staff, it would be largely up to you to ensure that the career threatening aspects resulting from candor were prevented.

6. This process should be applied to all Class A and B (flight, ground, and weapons) mishaps.

7. MAJCOMs should be required to provide experienced personnel (aircrew, maintenance, medical, etc.) instead of the current practice of assigning people who have not been on a board before.

30 PERCENT MANPOWER CUT

Currently HQ AFISC/SE consists of seven divisions:

Flight

Ground

Weapons and Space

Life Sciences

Systems Safety and Engineering

Reports and Analysis

Safety Education and Policy

Contrary to the title, Reports and Analysis actually does very little analysis, per se.  Reports proofing, archiving, Freedom of Information management, and data entry and retrieval is a more accurate description of this, the largest division.  Safety Education and Policy Division is also somewhat of a misnomer in that only 3 of the 20 authorizations are involved in "policy."  Most of the rest of the personnel are involved in publishing the Flying Safety and Road & Rec magazines (9) or managing the Air Force safety education programs and safety career field, both enlisted and civilian (5).  With the exception of personnel in the reports and data management areas, our personnel are thinly spread across the spectrum of Air Force specialties; e.g., we have only five fighter positions, including the branch chief, in Flight Safety to cover all fighter-related safety issues from concept to the boneyard.  We have one maintenance officer. Still, we can handle a 30-percent cut by physically reducing/streamlining reporting requirements, eliminating all redundant area coverage, and updating, reducing, and simplifying our automated data processing system.  The ADP restructuring is being worked now with AF/SC.

MERGE WITH AFISC/SN (NUCLEAR SURETY DTRECTORATE) AND MOVE TO KIRTLAND AFB

The 30-percent manpower reduction can be accommodated by SN with generally the same qualifiers listed above for SE applying to SN.

The move to Kirtland and the construction of a new building to house the Inspection and Safety Centers (FOAs) will require numerous management actions and close oversight throughout the process.  However, there should be no show-stoppers.

Both HQ AFISC/SE and SN are basically field organizations with the major portion of their work supporting field units/commands.  I do not see that changing with the reorganization.  Improved awareness, management, and reduction of risk in everything we do from mowing the grass, building the ATF, modifying the KC-135s, flying the B-2, or taking the family on holiday is our domain.  It is in that larger domain, where mishap sequences initiate and progress to a conclusion, that the Air Force safety program can best influence mishap prevention.  That's where the action is, and that's where we can get the best return on our investment.

To be effective, our safety personnel need to possess current expertise, and we need sufficient qualified and current personnel to cover the broad spectrum of Air Force activities.  Each must be involved and participate with the Air Force at large in their area of expertise; i.e., all rated safety officers with flight-related responsibilities should fly as RPI-8s.  At present, MAC supports a flier at an MC rate and TAC has supported the Director at a GO familiarization rate.  That is not sufficient.  All RPI-8 positions should be supported at an MS rate.

The policy implications of having an active, involved, and responslble safety organization and an Air Force safety program of the highest integrity should be straightforward and relatively simple.  Either we will have a thorough and candid investigation process or we will not.  As I have pointed out, passing the investigating responsibility around to whomever hasn't had to do one, or having the investigation serve as an 0-6 screening process, clearly undermines the credibility and integrity of the Air Force safety program.

Budgeting requirements to support the combined activities of SE and SN are minimal.  Our current combined budget (if fully funded), including O&M, civil service pay, contract servics, AFIT support, and publishing expenses. amounts to only slightly more than $10M.  Thus, our budgeting requirements are handled routinely as an additional duty--no more is required.

THE CREATION OF A CHIEF OF SAFETY REPORTING TO THE OFFICE OF THE CHIEF OF STAFF

A superb concept which has the potential to fundamentally alter the Air Force focus on safety depending upon how it is physically established.

If the implementation goes as currently conceived by the Air Staff, it will be the most gIaring example of irresponsible, bureaucratic empire-building I will have ever witnessed.  Our policy, programming, and budgeting manpower requirements, as previously outlined, are for approximately 2.5 man-years of effort.  The Air Staff proposal for a staff of 22 personnel would be ludicrous if it weren't so tragic.  Remember, we are an organization whose combined current authorized strength is 188 personnel with a $10M annual budget.  Incredible--think how many people you would need on the Air Staff to cover a field command like PACAF.

A second critical area of importance is what the concept is for the one-star.  Policy issues are not like a floating crap game requiring constant movement or restructuring--once made, they should, at your level, remain somewhat stable.  Otherwise, the field agencies will never be able to implement.  So, policy issues will not keep him busy.  Nor will the planning, programming, or budgeting necessary to fine tune a $10M budget. So the question of what you want this one-star to do day in, day out takes on an ominous potential.

All the technical, system, and field specialists, along with the mishap histories, mishap archives, and data base will be at either Norton AFB or Kirtland AFB.  If this one-star is to be the Safety answer man or adviser, he will be in the wrong place.  Most of what he needs to know about will be happening somewhere else--in the field.  Thus, in order to keep him from looking like a real dullard, the FOA will have to artificially inseminate him with knowledge--about 9 hours worth a day--or he "won't know what's happening."  The focus of the FOA will have to shift from mishap prevention interaction with the field and mishap investigation, to a passive gatherer and transmitter of information to their boss in Washington, the one-star "Mr. Safety Answer-Man."  He will get the reports from the FOA, and he and he alone will have answers to whatever anyone on the Air Staff wants to know about safety, and if he doesn't, he'll need some more reports to keep himself out front of all possible questions.  The resulting organizational reality will be a totally upward-focused FOA no longer involved with trying to prevent mishaps but totally buried by the AF/SE's demands for information.  The Pentagon staff will be pressed to ask for the latest information on mishap investigations.  We will be pushed to interfere with and disrupt mishap investigation boards asking for status reports.  "What's happening?" "What have you found so far?" "Give me all you have--the Chief wants to know!" The whole process will be counterproductive as mishap boards struggle to not only complete the investigation but also track and explain why what they thought or said early on in response to a question is no longer the case and why.

General McPeak, if your desire is just to have a safety organization for appearance, with sufficient manpower authorizations to make a token but visible statement about how much we care about safety, while the reality is a passive organization processing information for the Pentagon with no active role in mishap prevention, the organization currently evolving will get you there.

However, if you and the Air Force are serious about having an effective safety program which stresses mishap prevention through constant productive interaction with the field Air Force; thorough, detailed, and candid mishap investigations; and corrective action--a safety program with purpose and integrity--then you need to redirect the ongoing reorganization.  My specific recommendations are:

1. The Chief of Safety should be dual hatted as both AF/SE and Commanding General of the Field Operating Agency.

(a) His primary location should be with the FOA.

(b) He should visit HAF on a frequent, periodic schedule.

(c) The Pentagon office for AF/SE should consist of Policy, Prograrmning, Planning, Budget Division with an 0-6 chief, secretary, three action officers, and an office for the SE on his frequent trips to HAF.

(d) An alternative to this divided organization would be to place the entire Safety Center and staff at Andrews AFB MD.  This would provide rapid, ready access by the Chief of Safety to your call, and a more efficient and effective safety organization.  However, it would require a change to base closure legislation.

2. The FOA, under the leadership of its Commanding General, should continue the current functions of field interaction plus:

(a) Annually present assessment and analysis of the top 10 rank-ordered risk issues to CSAF and review previous year's issues and fixes.

(b) Develop a practical risk reduction program that accomplishes the intent of federal environmental, occupational health, and safety guidelines while focusing on getting the job done at the unit level.

(c) Provide commanders of operational training with mishap lessons learned and trends in human failures so they can affect appropriate behavior modification through improved supervision and training.

(d) Provide traveling multiple-discipline teams to conduct risk assessment, safety analysis, and assistance to local commanders. Not an inspection--a true safety assistance visit.

(e) Conduct all Class A and B mishap investigations stressing absolutely thorough, candid identification of cause(s) and recommended corrective action.

(f) Provide trained and experienced board presidents and investigators and coordinate all special technical assistance required by the board.  MAJCOM experiencing the mishap would provide the remaining board members and support.

(g) Brief the board's formal report to all involved/interested MAJCOMs and HAF.

(h) Receive/consider/include, as appropriate, affected MAJCOMs comment on mishap report.

(i) Publish mishap letter of final evaluation.

CONCLUSION

I know you are a busy man.  My concerns and recommendations are not submitted lightly.  Even though I'm retiring, I leave behind many friends and a son flying Air Force aircraft.  Thus, I would like to leave behind an Air Force safety program of the highest integrity and substance--one that actively strives to assist mission accomplishment while keeping our people alive and resources intact.  We've been evolving in that general direction for the past 40-odd years as a result of many, many lessons learned the hard way.  We need to keep the momentum headed in the right direction.  My 30 years of rated flying experience and the past year as your Director of Aerospace Safety tell me the current proposal of a self-serving, upwardly focused Safety staff in the Pentagon is very simply, WRONG.  If you would like to discuss any or all of these concerns in greater detail, I am certainly willing, ready, and able to do so at your convenience.

Very respectfully

JOEL T. HALL

Brigadier General, USAF Director of Aerospace Safety