Bone of Contention

B-1B crash investigation report raises eyebrows and questions

Occasionally, the Air Force will have a serious aircraft accident.

When this happens, investigations are conducted and reports are written. Eventually, a report is released to the public.

Such reports are incomplete by design. Sometimes, the incompleteness does no harm. Causes still get addressed. Accountability still gets exercised. The public still understands the essence of what happened, and is therefore a step closer to forming accurate judgments about the health and readiness of its air defenses.

Sometimes, the incompleteness harms these objectives. Causes are obscured. Accountability is selective or untriggered. The public is misled.

When this happens, it’s because the unique design of the safety process gets abused. Subtle agenda control, selectivity, and innuendo are employed to avoid damage to the institution while quenching thirsts for explanation.

When this happens, we need to see it, say it, and contend with it. Or one day, we will wake up to a broken air defense and not understand how we arrived there.

What we will understand is that it’ll be too late to save the bureaucracy from itself, much less ourselves.

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In January of this year, two B-1B Lancers took off from Ellsworth Air Force Base in South Dakota on a routine training mission.

One landed safely. The other crashed while attempting to land. All four crew members ejected and survived. The aircraft was destroyed at a cost of $456 million.

On July 25, the Air Force released the investigation report.

It is incomplete by design. In this case, the incompleteness is not harmless. Indeed, it’s more obvious and more distressing than we can passively tolerate.

The report raises questions about the organizational culture and basic readiness of those operating the B-1, known as the “Bone.” But through innuendo, selectivity, and omission, it leaves the questions it raises enshrouded in a cloud of ambiguity.

There is clarity about what happened. There is too much mystery about why.

Before I explain, let me support what I’ve said about the process always being incomplete by design.

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One Event, Two Stories

The Air Force actually investigates serious accidents twice. The reports we see in the public domain represent the second phase of the investigative process.

The first phase, which starts immediately after a mishap, is called a Safety Investigation Board (SIB). The purpose of the SIB is to rapidly understand what caused an accident. It is a safety process, not a legal one.

SIBs use something called safety privilege to protect certain information they gather. Privilege helps investigators get the truth from people, not a manicured or varnished version. Truth is the fastest pathway to action that can protect the broader fleet. There are no lawyers in the interviews.

Once the SIB is complete, investigators provide the non-privileged sections of their report to an Accident Investigation Board (AIB), which conducts a separate investigation.

The AIB is a legal process. It exists for all purposes other than safety. This includes establishing evidence which could be used in determining legal liability.

The focus of the SIB is generating internal recommendations to make the Air Force safer. The AIB doesn’t recommend anything. It simply forms an opinion.

Publicly, we get access to the AIB report, but not the SIB report. Since the AIB doesn’t contain privileged information, we know it will differ somewhat from the Air Force’s internal understanding.

But depending on the particulars of a mishap and what goes behind the wall of privilege, it’s possible for the AIB to reach entirely different conclusions through different reasoning.

The creates a challenge for public accountability.

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Does the Loophole Swallow the Process?

Not knowing the extent to which the Air Force’s publicly noticeable actions are rooted in privileged information makes challenging or falsifying the justifications of those actions all but impossible. It gives the service a free hand in dealing with its most serious process breakdowns.

The concept of privileged information is a critical hinge. What is determined to be privileged can’t appear in the public record. This bounds the legal exposure of involved individuals and the service.

Officially, it does this to ensure our defense activities can be kept safe.

Unofficially, it creates a temptation for abuse, with shifting interpretations of what does and doesn’t go behind the veil employed to shape a narrative of what actually happened. This is a dangerous loophole for bureaucracies, which can be relied upon to protect themselves at the expense of principle.

Because of this, we can end up with public domain reports that seem to conceal the most important parts of the story.

This isn’t another anti-bureaucratic whinge on my part, though I could be forgiven. It’s just a realistic assessment of a process designed with built-in double-dealing.

The good news is that with a trained eye, it’s possible to make more complete sense of an AIB report by analyzing the spaces between what it says, the implications and tacit acknowledgements of what it doesn’t say, and noting how it supports its conclusions (or doesn’t).

When we do that, we sometimes expose questions the Air Force has deliberately chosen to not answer. And we are sometimes moved to contend with a report despite a neatly manicured public record of events.

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Key Conclusions

As reported by several media outlets, the B-1B report concludes the accident was caused by crew error. The pilot attempted a rushed approach in visibility below prescribed minimums, and made control inputs that caused his airspeed to drop and an excessive sink rate to develop. He failed to notice and correct these issues rapidly enough.

His crew failed to properly back him up. The aircraft struck the ground short of the intended landing point at a high vertical velocity and not under sufficient control to complete a safe landing. The crew ejected. The aircraft skidded to a stop and burned to cinders.

But this AIB is different from most. It goes further, or at least purports to.

Raising eyebrows by making assertions we seldom see made publicly, Colonel Erick Lord occupies the report’s section on “contributing factors” with scathing views concerning leadership of the involved organizations.

He says the two squadrons involved — the 34th Bomb Squadron (34 BS) and the 28th Operations Support Squadron (28 OSS) — lacked adequate supervision. Also that they lacked proper levels of discipline and airmanship, which is an impeachment of training and readiness routines.

Ultimately, the Board President scrubs away any remaining doubt about his opinion when he invokes the magic words

“I find by a preponderance of the evidence that these leadership and climate issues directly contributed to the mishap.”

This is seismic.

But even more thunderous is the shockwave created by what isn’t said.

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Key Omissions

There are three facts not mentioned in the report which should be. They are directly relevant to its conclusions. Their exclusion makes the report incomplete.

Let’s briefly discuss each.

• Staffing Levels.

Every Air Force unit is authorized a particular number of airmen in particular specialty codes. This is the staffing level required to conduct its assigned mission.

Units are then assigned airmen to meet that staffing level. Not uncommonly, units are staffed short of requirements. This requires each individual to stretch and cover more workload, and at some point results in the unit being unable to cover all requirements.

Col. Lord’s report says the 28 OSS commander’s decisions on which roles to staff and which to leave vacant resulted in a lack of adequate supervision. He says this contributed to the mishap.

There are three problems with this assertion.

(1) In conceding that the commander needed to decide which roles to leave vacant, Lord tacitly stipulates that the squadron did not have enough personnel to fill required roles. But he stops short of making this explicit, and doesn’t raise questions or introduce analysis on the reasons and impacts of understaffing. He simply casts blame upon the unit commander without clarifying how little influence squadron commanders have over the demands placed on their units or the staffing they are given.

(2) Lord treats the commander’s staffing decisions as incorrect, misleading the report’s audience into believing there are “right” and “wrong” answers in an understaffed scenario. Given the centrality of his assertions of poor leadership and the degree to which he relies on staffing decisions to level those charges, he needed to disclaim that these are judgment calls. That they are dynamic and circumstantial, and that they illustrate a failure of the parent command and service to provide adequate resources to the commander.

(3) Lord never deals clearly with staffing levels of either squadron. He gives us the assigned headcount of one squadron but not its authorized staffing. He gives us the authorized headcount of the other squadron but not how many are actually assigned. This makes the report inconclusive on the actual health of both organizations.

Staffing levels are not privileged. There is no bar to their inclusion in the investigation or the report. They are important to the story of this mishap.

Excluding this information cuts a deep flaw into the report. If staffing was not investigated, then Lord’s conclusions connecting to unit health can’t be trusted. If it was investigated but not included in the report, then we can’t trust we have a complete enough record to understand the mishap.

Either way, we don’t have a full story, and confidence in the report is impaired.

• Deployment Timing.

During the time this mishap unfolded, the Air Force was in the stride of trialing a new force presentation construct. The first deployment under this construct kicked off in October of last year and stretched through April.

Airmen from Ellsworth deployed. Others backfilled deployers from the service’s other B-1B wing at Dyess Air Force Base in Texas to sustain its home station activities.

Because of the senior sponsorship and political profile of this deployment, which is proving dough in the Air Force’s readiness assessments and budget proposals, no exceptions to the deployment were granted according to insiders.

We don’t know what impact this had on Ellsworth’s staffing or experience levels. We don’t know what critical skills may have been missing, limited, or overstretched. Therefore we don’t know what impact this may have had on the ability of commanders to keep airman trained and proficient.

The deployment should have been mentioned if only to disqualify its relationship to Lord’s conclusions. He says there is evidence of failure to provide proper training.

But nowhere in the AIB report do we see such evidence mentioned. The unfolding of a manpower-stretching deployment in the background of the mishap is directly relevant to this conclusion. We don’t know why it isn’t mentioned, but it feels like an attempt to have it both ways by criticizing readiness without implicating a politically favored challenge to that readiness.

• Group Change of Command Timing.

Lord invokes culture and leadership in two squadrons which both fall under the 28th Operations Group (28 OG). He says airmanship is not in a good place, which is a way of saying the fundamentals of the Ellsworth operation are shaky.

This directly targets the competence of the 28 OG commander. Little surprise that in the aftermath of the report’s publication, that officer, Col. Mark Kimball, has been sacked.

What the report leaves out is that Kimball had been in his role less than six months at the time of the accident. That’s not enough time for Kimball to be responsible for the entire arc of degradation Lord describes in the AIB.

Nor does Lord mention that Kimball’s predecessor is now his boss, 28th Bomb Wing commander Col. Derek Oakley. Prior to Kimball taking command, Oakley held the role for two years.

Lord’s assertion of failing cultures and decaying fundamentals is offered in conclusory fashion. There is no support in the AIB for his charges of organizational decay. Lord doesn’t even tell us what, if anything, any of the commanders involved have done or failed to do in response to previously noted cultural maladies or readiness concerns.

And yet, he concludes leadership is the problem driving these other problems.

Many things can create a culture problem. Among them organizational structures, systems, resources, and demands relative to the health of the organization’s roster and the stability of the operation overall. It takes many leaders working in succession over a long time to build a strong culture, and vice versa. It doesn’t happen overnight in either direction.

By skipping any real analysis of culture or airmanship, Lord tacitly concedes these are either theories he chose to include despite their incompleteness, or that he’s omitted from the report the evidence he relied upon to be certain they contributed.

Whichever is true, the selectivity of Lord’s analysis fatally impairs the credibility of the report. He says the culture is broken, but we have no reason to believe him. In fact, we have reason to believe he doesn’t believe it. Else he’d have painted a clear contextual picture within which the assertions could be understood.

By leaving out that Col. Kimball lacked the tenure to be solely responsible for the organizational issues, Lord avoids wrestling with thornier questions about whether and to what extent those issues existed under Oakley. And therefore, whether that previous commander bears any culpability, whether his promotion to wing command was appropriate, and whether there is any conflict of interest in Oakley firing his successor over issues that began or at least existed during his own time in the role.

Lord’s selective investigation laid the groundwork for selective accountability.

No surprise airmen within the B-1B community and beyond are asking whether Kimball has been scapegoated. And every taxpaying citizen should be asking whether the investigation’s conclusions on culture and airmanship are correct. And if so, whether they’ve been properly addressed.

There’s something else I want to mention here. Something which is less weird and more obviously grimy.

This accident occurred in early January. Within days, the SIB will have known the essence of what happened and why. Not later than mid-March, the SIB will have reached and communicated its conclusions.

If Mark Kimball was sufficiently culpable to be removed from command, it should have happened at that stage. He’s been permitted to stay in command for four additional months, and only sacked as a response to the AIB release and ensuing backlash.

This means his firing was reluctant. It was done as a political imperative, and doesn’t reflect genuine concern.

While Oakley pulled the trigger on that firing, the gun was handed to him by higher headquarters. Generals with multiple stars are the hiring officials for O-6 group commanders, which means they are also the firing officials.

Firing a group commander over “culture” but not firing his predecessor makes sense politically. Because to fire a wing commander raises bigger questions that start implicating the inconvenient themes I’ve touched upon.

If Kimball was fired as an attempted political firewall, the general(s) who made that decision are trying to pacify a conversation. We need to understand what they are protecting.

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Unspoken Presumptions and Missing Support

The absence of cultural analysis is a huge problem for this AIB report. And this is unfortunate, because there was an opportunity here, ironically, for the Air Force as a whole to take a cultural step forward.

Mishap reports usually blame pilots or crews and stop short of asserting much more. It’s axiomatic. Because in any mishap chain, you can find fault with how a pilot has performed.

Too often, there is a more complicated story that doesn’t get told. And every time this happens, the Air Force undermines one of its own primary cultural pillars — the use of rigorous, truth-seeking debriefs and root cause analyses to learn and improve with every sortie.

So, in a sense, I’ve always longed for a moment like this one, where leaders are not spared accountability for the conditions they’ve created. A moment where we get beyond the pilot and crew and into a broader analysis of what led them to their fates.

But the idea of holding leaders accountable rests on a knife edge.

Get it right, and you make the rank and file more trusting and confident. Get it wrong, and it looks like scapegoating, which undermines trust and fosters cynicism.

How it turns out comes down to whether the investigation is professionally conducted. Truth-seeking investigations use evidence to disqualify potential factors until only the relevant ones remain, supported by clear data.

Unprofessional investigations start with a working theory and then find enough support to hold it plausible. This leads to stretching evidence, omitting or downplaying inconvenient facts, and to making assertions that lack sufficient support.

In this case, the lack of evidence to support the finding of degraded culture and decaying airmanship undercuts confidence in these conclusions. Moreover, it raises the question of whether inconvenient truths are left out to make those conclusions appear safe.

Lord tells us leadership is to blame for poor culture and airmanship, but he doesn’t say why. This leads me to wonder what he presumes about the commanders involved.

Does he believe they wanted their teams to fail? To die in accidents? Does he believe they were incompetent despite years of development, experience, and preparation for their roles? Despite the highly selective processes they endured to be appointed?

These are the implications we’re left with, because Lord doesn’t tell us why or how the involved leaders have failed.

Commanders never want to fail. They never want their teams to fail. They seldom are inept enough for their negligence to contribute to a mishap.

So if they are at fault, the explanations lie elsewhere. Development, selection, experience, and the extent to which they and their organizations are properly supported to achieve their missions.

The presumption of poor local leadership is unsupported, at least on the basis of the evidence furnished.

Bad presumptions lead to bad solutions. Bad solutions lead to repeat mishaps.

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Planning to Fail

There are contrary schools of though in the Air Force aviation community when it comes to the subject of mission planning.

Traditionalists believe most of what happens in execution of a training mission is directly traceable to the quality of planning. Sorties are typically planned the day before, consuming several hours. Crew training requirements, detailed studies of planned maneuvers, and creation of supporting products are instructor-led matters of obsession in a routine dating to before the Air Force had its own name.

Non-traditionalists see this as over-investment. They seek to automate planning. To make it more efficient. To reduce the time and thought required to accomplish it. And to mature aircraft systems and operational processes to the point that it’s no longer required.

For a few decades, the non-traditionalists have been winning this intellectual tug-of-war. Planning time and emphasis have been shrinking.

To publish my bias, I am a traditionalist. As a pilot climbing the ladder of qualification, I adhered to the custom of having the day prior to a training mission completely protected by schedulers.

Later, as a squadron commander, I extended and helped protect this norm from the relentless clutches of bureaucrats. The time to think together and rehearse together has always been the point of planning. And planning is especially important during a formal upgrade, when a pilot is making the transition to greater responsibility.

The crews involved in the Ellsworth B-1B crash did not plan. They flew their mission on a “show and go” setup, which means they spent an hour or two reviewing mission details that had been provided by support staffs before stepping to the aircraft to fly the same day. There was no planning session.

In my view, this is massively significant to the accident.

The situation included a pilot in formal upgrade training for aircraft commander. That pilot had a history during previous training courses of needing instructional support to execute stable approaches. The entire crew had limited recency in the aircraft. The weather wasn’t great, which is normal for South Dakota in January. The instructor pilot had flown just twice in two months.

These are all arguments for a methodical planning session to walk through the primary plan, discuss contingencies, and review the fundamentals of things likely to happen.

With more robust planning, the crew might have thought in more depth about the challenges they would face in the event of an instrument recovery to Ellsworth in low visibility and/or shifting wind conditions.

This didn’t happen. When weather conditions degraded during their flight, the crew had to change runways and approach plans on the hoof. This, combined with low proficiency, led to a rushed approach. Anytime a crew is rushed, the likelihood of a lapse in situational awareness is greater.

Which is exactly what happened. Due to a litany of communication errors dating back months, the landing runway was not fully equipped for poor weather. The crew didn’t know that. Had they uncovered this fact during planning, it might have broken the mishap chain.

Lord lists airmanship, pilot execution, weather, airfield status, and crew resource management as causal or contributing to the mishap. But he does not connect these issues to mission planning, where all risks associated with them could have been eliminated or mitigated.

Situational awareness, and therefore safety, begin during mission planning. The fact Ellsworth crews were operating on a “show and go” posture, even for formal upgrade sorties, is a big deal.

This is downplayed in the report. We are left to wonder again whether this is a reflection of deficient reasoning by the AIB or a fact deliberately elided in order to avoid conclusions which could be damaging to the broader command.

If crews are routinely flying the B-1B without mission planning, there is a problem. One that deserves more investigation.

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Conclusion

There are some who have privately questioned why Col. Erick Lord was permitted to lead this AIB and publish this report. He shares a community with the involved commanders. He presumably knows them. He competes with them for promotion and leadership roles. He could be seen to have a motive to paint them unfavorably.

I don’t see clear foundation to ask those questions. Though I question why generals wouldn’t choose someone else if only to avoid any appearance of a conflict of interest, it’s also the case that Lord is entitled to the presumption of integrity.

He is not entitled to a presumption of competence, however. And in my view, this report leaves a lot to be desired.

All AIB reports are incomplete by design. All are stories about what happened rather than full factual representations.

But while incompleteness and double-dealing are often harmless elements of the safety investigation process, they sometimes create defects corrosive to safety. Sometimes, they seem to be employed as political devices to spare official blushes.

This report wants to have it both ways.

It paints the picture of a community in crisis, with basics and flight discipline at a premier bomber base decayed. Yet it doesn’t want to ask questions about staffing, resources, or mission demands.

It claims airmanship is not in a good place, but avoids probing things which support its cultivation, such as mission planning, squadron experience levels, and operational tempo.

It tells us organizational culture is a problem, but doesn’t tell us how long that’s been the case, why it’s the case, or how that conclusion has been reached.

This sort of duplicity is usually the smoke of a structural and systemic fire. A fire that requires a response more fulsome than scapegoating an O-6 and moving on.

Col. Mark Kimball may indeed be culpable for failing to notice or react properly to cultural problems in his command. It certainly feels like the right questions weren’t getting asked when an airfield can be impaired for months and no one seems to notice or care.

But his firing, if necessary, is not sufficient.

We have here a report that should make Americans worry about the readiness of the entire B-1B community. Which is another way of saying we should worry about our entire strike capability, which is a pillar of our defense.

And yet, the report asks no questions about broader systemic issues. It wrings its hands. But then lays everything at the feet of a couple of squadron commanders. People who have little to no real authority over any of the substance of the issues implicated. They execute. They don’t organize, equip, or allocate resources.

Almost as if to prove it is a device of politics rather than safety, the report has been precisely weaponized, taking out one commander while leaving superiors and subordinates untouched.

The Air Force would like us to accept this. After all, we don’t have the whole story. By design, the account we have and its conclusions are incomplete products of a process which needs to conceal some of itself for good reason.

But we can’t allow that deliberate incompleteness to become a trap door through which the intent and usefulness of the entire process fall.

The report omits material facts and analysis which are not privileged. Which could have and should have been included. The report quarrels with itself, grasping at systemic straws but ultimately leaving them untouched in favor of tactical-level critiques that allow the matter to be neatly concluded.

We need something better than this.

The Air Force needs to address the deficiencies in this AIB. As released, it is harming confidence among airmen and gives the public too little reassurance that the problems leading to this crash are being addressed.

Nothing short of our ability to defend ourselves is at stake.

Tony Carr is a retired Air Force squadron commander and deputy group commander with formal training and experience as a safety board president.