Doing What is Right Can be Painful

Now, this is an interesting story. It occurred in 1979 during my second year as Director of Operations at Osan Air Force Base in South Korea. 

In the Air Force, when you have a major aircraft accident, you convene an accident investigation board to determine the cause and any remedy that might be required to prevent or at least reduce future accidents. The president of the accident board is a full colonel and a pilot who is experienced flying the same type of plane as the one in the accident. The accident board comprises the colonel who leads it, one or two other pilots, airplane factory technicians sent in from the United States, doctors who do the forensic stuff, and all in about eight or more highly capable people—a very strong team. The goal is to complete the investigation and determine exactly what happened within 30 days. As the president, your task is to assemble this group of specialists, investigate the accident thoroughly, and come up with a very long and complete written report on exactly what happened, why it happened, who's to blame, what went right, and what went wrong.

Anyway, it turns out, that in the Philippine Islands, outside of our primary air base there, Clark Airfield, an F-4 fighter jet piloted by one of their best pilots, a Weapons School Graduate (the Air Force’s “Top Gun” school), with the weapons systems officer (WSO) in the backseat crashed on a high speed low level entry into the gunnery range over the jungle in northern Luzon. The pilot and WSO were killed. The aircraft was spread all over the jungle in a million pieces. And I was appointed to be the president of the accident board.

I'd been involved in accident boards before, not the least of which was my own accident, but then I was the guy being investigated instead of the other way around. So anyway, here I am, the head of this thing. And we pack up the family for a little month-plus vacation, at least for them, and head down south to the Philippine islands to set up the investigation board. It was an interesting experience. It's a little bit like being a crime scene investigator, where you assemble all the clues from all the collected technical data, forensic information, and pieces you can gather, and you usually can determine the cause of the accident and who or what is to blame. In a lot of cases, quite frankly, it is pilot error. Pilots are human beings, at least most of us are, and we make mistakes. We don't make mistakes often, but every once in a while, we do. And when you do, it can kill you. So, the idea is to decide what caused it. Was it the pilot who caused the crash and the fatalities? Was it a mechanical failure of some catastrophic level? Was it, I don't know, weather, control tower? I mean, who knows? 

Anyway, I'm down in the Philippines and I'm investigating it, and we're putting together all the bits and pieces that we could find in a hanger. A little bit gory. When you take an airplane at 500 miles an hour and roll one into the jungle, you end up with a million pieces. I don't know about a million, but hundreds of thousands of pieces, literally. And part of those pieces, unfortunately, are from the crew members. That gets a little bit gory. But you must have the pieces for the doctors doing the autopsies and stuff like that. 

So, we're working, assembling all this information on the accident, and for whatever reason, after about week two or maybe going into week three, it's just not coming together. I don't know; something about it just doesn't make sense. About that time, I got a phone call from the Flying Safety Officer at the headquarters of the Pacific Air Force. He told me, "The four-star Commander of the Pacific Air Force is really antsy to find out the answer. And by the way, he said, 'It's clear that it's pilot error.' So, as the accident board president, he wants you to find out why it was pilot error, declare pilot error, close down the investigation, and let's get on with life." And I said, "Well, I can't do that yet. I can't. I don't have the answers. I don't know what caused the accident." And he says, "Yeah, but you don't understand. The four-star said it's pilot error. You're in charge. Go figure out why it's pilot error, close down the accident investigation, and let's get on with it." Oh, great. So, I said, "Listen, I can't do that. We just don’t know yet what happened but so far it doesn’t look like pilot error.” 

I had another, whatever it was, 10 days to go. Let's see where it leads. So, after about two weeks of work, I'm still not getting anywhere. Something is just not right. So, I grab one of the fighter wing’s best pilots, an F4 pilot from the squadron, and he and I go into the flight simulator and try to recreate the mission. And we did. The simulator guys worked all the magic and cranked it up so we could come close to simulating the mission. 

Strangely enough, we couldn't duplicate it. I mean, the two of us must have run through the SIM, or simulator, I don't know, more than a dozen times, and never could duplicate it, which led us to believe something was wrong that we weren't aware of. It wasn't pilot error. There was something else going on. But we couldn’t figure out what it was. So now I'm just about out of time. My thirty days were up, and I got a very harsh phone call from the four-star Commander of Pacific Air Force headquarters that said, "Close that thing down right now and declare pilot error."

Well, as it turns out, as the president of the accident board, theoretically, I do not have to shut down the investigation. I can keep it going until I'm satisfied that we found the right answer. So, I go back through the staff guy, and said, "I am not shutting the investigation down because I don't think that it’s pilot error. Something else happened to cause the accident. So, I'm going to continue the investigation until we find out the correct cause." Another seriously bad career move.

Well, now I'm desperate. I needed to get more data. I needed to get more clues. I needed to find out what we were missing that might still be in the jungle along the flight path prior to impact. Day after day we rooted around in the jungle, searching for pieces of the wreckage but there was still stuff missing. So, I decided we needed to bring in more help.

I remembered that years ago, a close friend of mine in the CIA had to hide out in a headhunter village in northern Luzon, in a heavily jungled area. So, I went to the USAID (U.S. Agency for International Development) group from our State Department and convinced them to let me have a bunch of 50-pound sacks of rice so that I could barter with the villagers to help us out. Thanks, old friend. I didn’t know much about “headhunter” villagers, but my buddy lived with them for six months or so and survived, and I had lived with the Montagnards in Vietnam for a while, so I figured I could work something out with the chief of the village. Lots of free rice usually builds quick friendships in the jungle. So, next I got a helicopter assigned to support me and carry me and my interpreter and my rice and I flew up to the headhunter village. I landed in the center of the village. I thought it would be a good idea to make a grand entrance, and I went to the chief and started my sales pitch. Before we started the negotiations, I thought it would be smart to set out the parameters of our discussion. It had occurred to me that if you’re in the headhunter business, you probably have to kill the person under the head first. So, I had the interpreter point out to the chief that if anything happened to me or my men, there would be no more rice because I would only have one day’s supply. Then, even worse, my Filipino military friends would come and destroy the village and kill the chief and his entire family, but him very slowly. To which he nodded his understanding. I said that I was looking for aircraft parts and any remains of the crew from the plane that had crashed in the nearby jungle. I described in detail the type of thing we were looking for. And I said, "And, if you'll send your men out to collect all the bits and pieces, then I will show up every morning, starting tomorrow, with rice, and I will pay you and them in bags of rice for everything that they find and turn into me." And the Chief says in his language and dialogue something to the effect, "Well, that's cool. We'll see you tomorrow morning.”  By the way, his cut of the rice deal was about 50%. Typical politician. 

So, I jump back into the chopper and get a couple of 50-pound sacks of rice, big burlap bags full of rice. And I loaded up the helicopter every morning for the next week or so. And every morning, I flew into the headhunter village with my bags of rice. And sitting next to the chief and his main guys, his people would bring in bits and pieces of everything they found in the jungle, and because they were getting paid for it, they found a ton of stuff in the jungle. By the time they were finished, they may have ended up with the cleanest jungle in Asia. They brought me bits and pieces, parts, relics from World War II aircraft, I mean, all kinds of things. It was amazing. And I bought everything, and I paid for everything in rice. And this went on for days.  And every day I’d collect everything, put it in the chopper, bring it back to the hangar, and we'd sort out what was relevant. And we'd test that and run it through all the labs and stuff like that. 

After four or five days, these guys started bringing in bits and pieces of the engine. And when we examined the pieces, not we, I shouldn't say, I didn't examine them, but the technical representatives from McDonnell Douglas and Pratt and Whitney.  They examined all the various recovered parts, then ran them through a lab back in the States, and they found that some of the blades on one of the engines were cracked, and at high speed and high RPM, they disintegrated, destroyed the adjoining engine, and all sorts of other components like the flight control system. The aircraft imploded and went into the jungle. Remember that the guys were running a couple of hundred feet above the ground at about 500 miles an hour. So, it only takes a hiccup to drive the plane into the jungle. So, finally, now we know the truth. It was a massive explosion, the bird imploded, and two good guys were killed. By this time, I'm about five to six weeks into the investigation. And when you talk about heat from the four-star general at the Pacific headquarters, I was indirectly getting very fiery comments from the four-star. To make a long story short. By the time we got everything in, we could conclude that it wasn't pilot error at all. It was a failure of the engines and aircraft, and there was no way in the world that the pilot could have recovered that aircraft. Then we went out worldwide to all of the fighter bases with the same aircraft and engines, and we found eight or 10 other engines in the field just like the one from our accident. They had come from the same depot with the same flaws and fatal characteristics for failure. We were able to pull them out of service, send them back, repair and replace the damaged portions, and thereby presumably save the lives of a dozen or so guys. I was proud of that. I was proud that I took the heat and came up with the right solution to the problem, and that it wasn't pilot error at all. It was a mechanical failure.

The end of that was a very cool reception from the staff at Pacific Air Force headquarters and a verbal reprimand from the Commander of the Pacific to the effect that I had disobeyed him. He was right. I did. But I thought it was essential to do so.  From that point on, I was on his blacklist. However, I felt that I had redeemed the pilot and the weapons systems officer, and that their families would know that their deaths had absolutely nothing to do with their skills or abilities. So, the four-star commander was not very happy with me, but I was pretty happy with myself. I knew you must do what is right, even if it is painful. A good leader must always be ready to take one for the team and do the right thing.