In his History of the Peloponnesian War, Thucydides wrote: "It is a common mistake in going to war to begin at the wrong end, to act first, and wait for disasters to discuss the matter." Such was apparently the case in Southeast Asia in the 1960s. Chief of Naval Operations Admiral Thomas H. Moorer directed the creation of the U.S. Naval Fighter Weapons School in response to poor tactical performance in the skies over Vietnam. After heavy aircraft losses and only achieving "about one kill for every ten firing attempts," the Navy conducted an investigation into air-to-air combat performance. The study found inadequate aircrew training to be a major factor.1
Today, our safety performance warrants this same type of study. The Class A mishap rate over the past ten years is about 1.5.2 That means we are significantly damaging or losing a life and/or aircraft every month. We were charged by Secretary of Defense Robert Gates a few years ago to lower our accident rate by 50 percent. We can do it, but it will require novel ideas, appropriate training, and discipline. The Naval Safety Center is constantly seeking ways to catalyze the next major reduction in human error. The answer lies in our people.
In the September 2006 issue of Approach magazine then-Rear Admiral George Mayer wrote an article titled "The Blue Threat," the threat being "our errors and poor decisions." He also identified the familiar causes of "communication . . . confusion, preflight planning and briefing weaknesses, complacency, and a lack of assertiveness."3 Add to this something we'll call the Gray Threat.
Beyond the Blue Threat
The Gray Threat has two facets. First, our F/A-18 A-D model Hornets are wearing out faster than we can afford to upgrade or replace them. Second is the potential for complacency in the current operational environment. Senior leaders often refer to the present generation of service members as the most operationally experienced since the Cold War. They don't often like to admit that we are also the most war-weary. Rote exercises and fatigue are a dangerous combination. We have proved that complacency is an insidious killer. We must continue to be innovative, especially now.
Although it has been flying for more than 30 years, the F/A-18 is still challenging us to remain mentally durable and flexible. The Marine Fighter Attack Training Squadron (VMFAT)-101 crash in December 2008 is a reminder that we have not worked out all of the technical and operational details of degraded mode operations. The mishap investigation results found poor maintenance, errors by the pilot, and errors by personnel on the ground to be the cause of the accident that destroyed a home in San Diego and killed four civilians.4 When I was a student in VMFAT-101, a civilian instructor told me that I should master degraded modes—salient yet uncommon advice.
The Hornet fleet is in for heavy weather just over the horizon because of multiple factors. The lack of spare parts means we are flying those parts to failure. The current operational tempo is demanding more than expected from the aging fleet. Today's strategy of service-life extension mitigates operational risk yet exacerbates safety risk. We are beginning to see failure modes that we did not plan for in the F/A-18, from on-board oxygen-generating system fires to rapid decompression and low-altitude hypoxia.
The present state of the economy and defense budget trends signal no relief from our materiel woes. This storm may be out of sight as we focus on supporting operations in Iraq and Afghanistan, but it should never be out of mind. It is not a matter of if you will have a system failure, but when. We should strive to become masters of the basics, balance, and the buddy system.
The Basics
The following is an excerpt from the Preface to the Naval Air Training and Operating Procedures Standardization (NATOPS) manual for the F/A-18 A-D models:
[The NATOPS manual] provides the best available operating instructions for most circumstances, but no manual is a substitute for sound judgment. Compound emergencies, available facilities, adverse weather or terrain, or considerations affecting the lives and property of others may require modification of the procedures contained herein. Read this manual from cover to cover. It is the air crewman's responsibility to have a complete knowledge of its contents.5
This is the most important section in the NATOPS manual and was covered in my initial Fleet replacement training. However, my lack of experience in the weapon system and operating environment prevented my full understanding of the gravity of these words.
Our training is precise (tightly focused on the right things) but not always accurate (centered on the target in space or time). The material we provide new students to guide them in the transition from naval aviator to F/A-18 pilot is the same type of information we should be covering as Fleet aviators to ensure we have the best basis for our decisions. I may be the exception, but I believe that many of us don't remember the depth of systems knowledge presented to us by military and civilian instructors when we were new students. This knowledge is where the answers, or at least the right questions, can be found.
The basics we all learned, forgot parts of, attempted to regain, and finally set on the back burner as we began to progress through our nugget years in the Fleet are exactly the place where we should be focusing our attention. What has changed more in the last decade, the TOPGUN (Navy Strike Fighter Tactics Instructor School) tactics manual or the NATOPS flight manual? While we're familiar with the revisions to the TOPGUN manual, we may be lacking in systems knowledge found in the NATOPS manual.
Another crucial section from the NATOPS manual is the General section of Chapter 12, Part V (Emergency Procedures):
Apply the following rules to all emergencies:
- Aviate: First and foremost, maintain aircraft control.
- Analyze the situation and take proper action. Perform immediate action procedures without delay; however, initially do only those steps required to manage the problem. When operating a control, be prepared to immediately return the control to its former setting if an undesirable response occurs.
- Navigate: Land as soon as practical, unless the situation dictates otherwise.
- Communicate: As soon as possible, notify the flight lead, ship, ATC (air traffic control), or tower of the emergency, aircraft position, and intended course of action. Relay emergency indications, actions taken, flight conditions, power setting, etc., as time permits.6
While these four rules may sound simple, they are indeed timeless and tested heuristics for reducing errors, gaining confidence, and building competence. We have all heard the saying "Aviate, Navigate, Communicate" since we were student naval aviators. Retired Commander Thomas "TT" Taylor, a civilian instructor at NAS Lemoore and former commanding officer with 3,400 single-seat jet hours, recommends that we "formalize 'Aviate, Navigate, Communicate' as a simple, easy-to-remember guidance on how to prioritize when handling emergencies. Teach it from the very first day of emergencies in the training command, all the way through to Fleet NATOPS checks." In a document that should be mandatory reading for all naval aviators, Commander Taylor describes a way to teach the guidance in emergency situations. Following are excerpts from his description of aviating in an emergency situation:
- Our historical accident rate is much higher than it would have been if aircrew had simply just flown the airplane and done nothing else.
- Once an aviator is doing a good job of flying, there will hopefully be a time when he has the brain power to continue on and do Bold Face [memorized emergency procedures] correctly. Because there are many "Immediate Action" emergencies that really are not immediate action, we think breaking up Aviate into two parts is an important part of training for proper execution in the emergency environment.
- For example, one Bold Face emergency which really is immediate action is settle off the catapult. This emergency requires that the pilot fly and do Bold Face simultaneously. The idea, again, is that most Bold Face does not require immediate action.
- Bold Face needs to be memorized and practiced enough to ensure aircrew don't forget it when the "rubber meets the road." There are many techniques on how people memorize and remember, and those could be taught to aircrew from day one. However, one point that should be made in training is this: In an emergency, every aircrew will experience a degree of adrenalin surge, the amount likely inversely proportional to one's level of confidence.
- If we realize how we will be affected, we can prepare for it in our training.
- Proper training could improve our odds of success by teaching how to compensate for adrenalin surge and how to properly prioritize.
We must share what works. "Aviate, Navigate, Communicate" works, and as Commander Taylor suggests, we should standardize how we teach it. We must analyze these rules and compare them to our current understanding and thinking processes. Then we must identify the gaps in our understanding and how to address them. Continuous improvement is the mark of a professional.
Experience allows a deeper understanding of the basics. What we learned in flight school and in the Fleet replacement squadrons can provide new insights to those who have more experience in the operational environment. This is not to suggest we all go back to the primary flight training or Fleet replacement squadrons. It does suggest that the training comes to us.
The Case-Study Method
Taylor's course on F/A-18 Hornet systems is what inspired this article. His class should be taught Fleet-wide. The course is an excellent overview of the aircraft systems, and it is taught using a case-study method that connects the systems to real-world situations. We studied a near-mishap and the resulting lessons learned, which covered every major subsystem in the aircraft. This integration of systems knowledge and case-study is a powerful tool that should be adopted by all units. Context is an excellent teaching aid.We also should have better distribution of hazard reports and safety investigation reports. Professionals who research aviation safety trends could provide further in-depth analysis of historical data. Major Brendan Powell, a Marine F/A-18 instructor pilot, says:
It seems that in our community we rely on local knowledge to some extent regarding systems failures in the aircraft. For example, I'm sure the Naval Safety Center has a ton of data on what happens when a failed engine is cranked in different circumstances, yet most aircrew live with a vague sense that cranking an engine is bad due to somewhat unclear statements in the [checklist]. Why don't all Hornet aircrew know exactly what could happen when they crank an engine that has shut down? After 30 years of flying these engines, that information must exist. At this point, we should rely on data and analysis of past [incidents] vice urban legend or merely local knowledge.
The Navy pays to have this type of data analyzed and stored. Taylor says that "reviewing a complex [Safety Investigation Report] with expert outside assistance could prove fruitful." Naval aviation should implement the practice of having experts relay context-specific aviation mishap trends and analyses to aircrew. Sometimes we need a little help.
The Buddy System
While it seems that we never have enough time or money in the military, there is no shortage of camaraderie. Whether it is the Marines stating that no man is left behind or the Navy declaring mission first, Sailors always, or the words on the POW/MIA flag, "You are not forgotten," these all attest to the military culture of fellowship. So what changes when it comes time to investigate mishaps? Human error is a causal factor in most mishaps, but organizational error is less so. We have convinced ourselves that there is a dichotomy between the organization and the individual. In truth, a failure of one is a failure of all.We train as a group, and we operate as a group. Even a NATOPS flight evaluation is a group event. How often does a fellow aircrewman accompany another to his/her NATOPS check? When we pretend that we are talking to the duty officer over the radio during a simulated emergency, why not talk to a potential duty stander? This training would be more realistic and benefit all involved.
Recent events have shown that duty officers and ground-based assistance to airborne emergencies need more attention. Commander Taylor states:
It would prove fruitful to incorporate ODO training during NATOPS checks to get real life experience. The aircrew are only half the equation; the support crew in the Ready Room needs training too. Just like chair flying is good prep but not the whole solution to a challenging flying event, CRM lectures and safety discussions are only part of the answer.
We are the protectors. So who protects us? Our culture of fellowship and camaraderie is one of our greatest military strengths. The answer is: We do. We protect ourselves from internal and external threats alike. We must reinforce the concepts of mutual support and crew resource management. The seven critical skills of crew resource management—situational awareness, mission analysis, assertiveness, decision making, communication, leadership, and adaptability—are not merely an annual examination question. Every naval aviator should be striving to perfect these skills. Mastering the basics is the foundation for excelling in advanced areas. Mastery as a team is essential to the way we operate. One obstacle to mastery is the lack of time.
Balance
I have heard Army leadership speak on the challenges of dwell time and operational tempo. In a 2007 hearing of the House Armed Services Committee, Army Chief of Staff General George Casey testified, "Our Army today is out of balance for several reasons. The current demand for our forces exceeds the sustainable supply."7 This example highlights the importance of balance. Without balance, we break the force. Is our training balanced? Does our training reflect the nature of current and future operations? This is not a simple topic, and I am raising the questions in hopes of sparking debate. This need for balance has multiple aspects. We must balance the schedule (when we can), readiness and competency, primary and ancillary training, and tactical and technical/procedural training. As long as we operate from aircraft carriers, basics should occupy as much of the conversation as tactics.What is more important, a tactical check-ride from the weapons school or a NATOPS unit evaluation? Based on the amount of time and resources focused on each, it would seem that the tactical check-ride is more important. Is that perception intentional? If so, is that the way it should be? One person's performance on a tactical check-ride does have an impact on the squadron's tactical reputation. As critical as that may be, crashing one airplane affects an entire unit in a way that no commanding officer, department head, division officer, maintenance master chief, leading petty officer, or brand-new airman wants to have to deal with. These are tough questions that need our consideration. I raise these issues because they are challenging. We can either drive this ship where we want it to go by addressing these issues, or we can let them work themselves out naturally and we will be left to pick up the pieces.
Stay Ready!
Something wicked this way comes; are you ready? The way to prepare for the unknown is through education and training. Contextual lessons learned, assimilated, and implemented will increase the likelihood of making sound decisions when faced with uncertainty. In a chapter on collective experience in the medical profession Dr. Edward Benzel defines clinical wisdom as "the ability to effectively assimilate data, observations, and previous experiences for the purpose of optimizing clinical decision making."8 We must optimize our operational decision-making capabilities as individuals and as an organization. We should be striving for operational wisdom. This is beneficial to our squadrons, all of naval aviation, and the Navy as a whole. For the F/A-18 community, training and education are our best weapons against the Gray Threat, and synthesis of the basics, the buddy system, and balance are the best tactics.No, my callsign is not MOTO (Master of the Obvious); I am merely restating much obvious yet pertinent truth. The Gray Threat is real and upon us. These lessons translate across platforms, communities, and even services, because they are inherently about people, not airplanes. Old aircraft we can handle. Old mindsets we cannot. Stay Ready!
1. Chief of Naval Operations, Report of the Air-to-Air Missile Systems Capability Review, Jul-Nov 1968 (Patuxent River, MD: Naval Air Systems Command, 1969).2. Naval Safety Center, "FY02-09 Navy Class A Flight Mishaps," http://safetycenter.navy.mil/
3. George Mayer, "The Blue Threat: Our Deadliest Enemy," Approach Magazine, September-October 2006.
4. Tony Perry, "Poor maintenance, critical errors caused jet crash, report says," Los Angeles Times, 4 March 2009.
5. Chief of Naval Operations, NATOPS Flight Manual Navy Model F/A-18A, B, C, D (A1-F18AC-NFM-000). Naval Air Systems Command. Patuxent River, MD: 2008 changed 2009, p. 51.
6. Chief of Naval Operations, NATOPS Flight Manual Navy Model F/A-18A, B, C, D (A1-F18AC-NFM-000), p. V-12-1. Emphasis added.
7. Gina Cavallaro, "Casey: Army strained by current demands," ArmyTimes, 30 September 2007.
8. Edward Benzel, "Defining Collective Experience: When Does Wisdom Take Precedence?" Clinical Neurosurgery, Volume 56 (2009), p. 49.
Lieutenant Commander Glover is a graduate of California Polytechnic State University, San Luis Obispo; Officer Candidate School (with distinction); Air Command and Staff College (with distinction); Air Force Test Pilot School; and the Naval Postgraduate School. He is a department head in VFA-195 stationed at NAF Atsugi, Japan, and embarked on the USS George Washington (CVN-73).