Dysfunction

“The Analysis of a Friendly Fire Accident using a Systems Model of Accidents” (pdf)

I thought this analysis of the shootdown of two U.S. Army helicopters by two U.S. Air Force F-15 fighters in 1994 was pretty interesting. Lots of people were somewhat negligent, and even in the face of a lot of safety procedures this was enough to cause a really bad accident on a particularly unlucky day.

According to an Air Combat Command official who was familiar with the official investigations, over 130 different mistakes were identified as being involved in the shootdown.

Some of the important factors were

• rivalry between F-15 and F-16 pilots
• “the poorest radio communications possibly ever given by pilots during a combat intercept”
• air controllers streamlining procedures that were cumbersome and usually not necessary
• incompatible radios
• generally poor communication

Nothing that would be unfamiliar to anyone working in a company with more than 10 people, probably.

Posted by jjwiseman at November 19, 2003 10:54 PM