The pilot had three, perhaps four seconds. According to the US General Accounting Office report, that is how long his pass lasted on 14 April 1994, when he had to identify two helicopters flying low along a valley over northern Iraq. He saw Iraqi Hind attack helicopters, his wingman did not object, and the two F-15s fired. They were two Black Hawks from their own side. All 26 people on board died. Why had he taken them for Iraqi? Because they were flying in the middle of Iraq, the pilot said later.
Above the fighters flew an AWACS, an airborne control centre, and the helicopters kept appearing on its screens in the minutes before the shootdown. No one on board intervened. Scott Snook, a lieutenant colonel in the US Army, an organisational researcher with a PhD and once a victim of friendly fire himself, spent two years investigating the case. His first chapter is called “How in the World Could This Happen?”
The explanation with no one to blame
The final chapter opens with Secretary of Defense William Perry’s words to the families of the dead: they will not have died in vain “if we learn from and correct our mistakes”. Snook takes it up: “We corrected many mistakes; however, what have we learned?”
What has stayed with me most from this book is his answer. Snook admits that for two years he hoped for the missing piece of the puzzle, the revelation in the next interview. He calls the part of himself that did so “the hubris-driven investigative reporter in me”. The missing piece never turned up. Instead he concludes: “There weren’t any bad guys; hence, no one to blame.” The accident was normal, he writes, because it was “the result of normal people behaving in normal ways in normal organizations”.
The page that follows is even more candid. Each time, Snook writes, he went into the data “hot and suspicious”, angry at the AWACS crew, puzzled by the pilots, and each time he came out “sympathetic and unnerved”: sympathetic because in their place he would probably have done the same, unnerved because that rules out every easy attribution of blame. Hence the chapter title, “There But by the Grace of God . . .”. At this point I wrote in the margin: “immediate reaction, old view” and “reflected reaction, new view”. Snook’s journey is Sidney Dekker’s distinction between the old and the new view of human error in miniature, lived through by a researcher who started out with the old view himself.
Three levels, three lessons
Snook breaks the case down into three questions and draws a lesson from each.
The pilots passed two helicopters in dark green camouflage at a distance of 1,100 to 1,500 feet and at more than three times the helicopters’ speed. An Air Force vision study could not say afterwards whether the pilots should have recognised the helicopters. The Hind, Snook writes, was the product of an ambiguous stimulus, strong expectations and “a perverse desire to see an enemy target”. The lesson is one of language. Ask why the pilots decided to shoot, and you inevitably end up with the pilots. Snook reads such tragedies first as “good people struggling to make sense”, not as “bad ones making poor decisions”.
In the AWACS, surveillance duties were spread across several people with deliberate overlap, as a safety net. The result, Snook writes, was the opposite: “Everyone was responsible, hence no one was.”
For the task force as a whole, Snook writes: “Just because it isn’t broken, doesn’t necessarily mean that it isn’t breaking.” For 1,109 days it had been reliable, and those very stable outcomes blinded its leadership. In 1992, two F-111s had already set up an attack on two Black Hawks and recognised them only at the last moment. It was never reported. It came to light only because two of the people involved happened to talk about it over a beer.
Practical drift
Across the levels, Snook calls the mechanism practical drift, which the book’s cover sums up as “the slow, steady uncoupling of practice from written procedure”. Rules are written for the situation in which all units work closely together. Day to day, each unit works on its own and adapts whatever does not fit its task. That is sensible locally and holds for a long time. Only when circumstances suddenly couple the units tightly do practices that no longer fit together collide. Snook’s phrase for it: “a normal accident in a highly reliable organization”.
Practical drift is sensible locally. It becomes dangerous only when circumstances suddenly couple the units tightly.
What remains open
Snook is clear about what not to do after an accident like this: treat it “as a potential crime instead of as a safety mishap” and pile new rules on top of the old ones. A footnote shows how high the price can be. A year later, an F-15 from the same squadron crashed because its flight-control rods had been cross-connected. The Air Force charged two mechanics, although it had known for ten years that the rods could be cross-connected. One of the two took his own life on the day his trial was due to begin.
Spotting the danger in advance is a step Snook leaves to his readers, and he says so himself: as practitioners we are “largely incapable” of recognising the conditions under which failure becomes more likely. For this, the appendix offers ten questions. The last one: “Is the focus on learning or on the ‘politics of blame’?”
What the bereaved are left with also remains open. Testifying before a House subcommittee, the widow of one of the Black Hawk pilots demanded to know how the AWACS crew could have failed to put two and two together. That no one was to blame is correct as a finding and hard to bear as an answer. Here you have to read on elsewhere, for instance on the question of who was harmed and what needs arose. An explanation without a culprit does not do away with responsibility. It only shifts where you have to look for it: towards those who could have shaped the seams between the units.
Who this book is for
Anyone who writes or signs off investigation reports, and anyone responsible for the interfaces between organisations. The book is academic but reads well. And if you find yourself outraged at the pilots while reading, you will end up where Snook ended up: realising that in their place you would probably have done the same.
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- Scott A. Snook – Friendly Fire: The Accidental Shootdown of U.S. Black Hawks over Northern Iraq, Princeton University Press 2000, paperback 2002 (main source)
- U.S. General Accounting Office – Operation Provide Comfort: Review of U.S. Air Force Investigation of Black Hawk Fratricide Incident, GAO/OSI-98-4, 5 November 1997