Andrew Stephenson’s Post

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Senior Tactical Systems Analyst

As a follow up to my post earlier on the use of the concept of privilege in aviation safety investigations, what do we do when ‘culture’ is a major contributing cause of a military aviation mishap? The recent report from the USAF on the January B-1 mishap in Ellsworth, ND is a quite blunt and straightforward, and I commend the board for writing it, and frankly the Air Force for releasing it. I have seen too many mishaps of this sort, where culture played a strong role, where the reports never see the light. And the issues never change because of this opacity. This report may not bring a broader change either, because as others have mentioned there are even bigger problems outside the unit level. Issues like pilot manning shortfalls, training changes that take away flight time, reduced flight hours limiting proficiency, etc.—problems not limited to the USAF. But it honestly lays bare the many factors that played into the incident, called out all the ways this could have been prevented, and highlighted the fact that there is far more depth than simply pilot error. As an aviator, I have seen safety reports that were painful to read, because as a reader you could feel the cultural cringe. It is bad to put yourself in the shoes of fellow aviators, and can be even worse when you know the folks involved in the incident, you have flown with them—and you can empathize how they be came to be caught in in a culture that encouraged unsafe actions. What I find most troubling about this B-1 report is that it reflected a broader trend that I have seen in my own community, as mentioned above. And it is the type of incident I think that we will see more and more of. Aviator staffing shortfalls and the attempts to compensate for these shortfalls are creating unforeseen cultural consequences. I saw similar incidents in my last years of active duty, where on an approach ‘lack of a composite crosscheck’ created an unsafe situation, but the damaging effect was compounded by a lack of proficiency and experience from the senior member of the crew.  If you have seen this too, or are curious to know more, keep an eye out for future posts, as I don't have room to write it all here. Here is the link to the report, I recommend any platform aviator take a look and read it, beyond just the recent headlines, and consider what you can take away from it to make your next approach safer. https://lnkd.in/ghZ6X7RB (U.S. Air Force photo/Airman 1st Class Corey Hook)

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richard-snake -jackson

Team Member Odyssey Systems, Pilot-Engineer

3mo

Perfectly stated Andrew.

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