Professional Behavior and a deadly, avoidable accident: The Fairchild Air Force Base B-52 Tragedy and lessons we can learn.

Most of us do not remember or were never aware of what happened on June 24, 1994. It was a clear day in the state of Washington and a B-52 bomber crew, lead by Lt. Col. Arthur "Bud" Holland was preparing to practice at Fairchild Air Force Base for maneuvers it would perform for an upcoming airshow. Sadly, that afternoon, the B-52 crashed during a 'go around' near the base after it stalled. The weather was clear and there were no mechanical issues. It was clearly pilot error which led to the fatal accident which not only killed Lt. Col. "Bud" Holland but three other senior officers on board. Thankfully, no one on the ground was injured, but many family members witnessed the accident, and it's obvious their lives were profoundly impacted by this event. More importantly, the series of events leading to this tragedy highlights the importance of intervention when someone in authority 'breaks the rules.'

What's interesting is the story behind this story--the story of how an arrogant pilot was allowed to continue to fly. Immediately following the accident, Brigadier General Orin Godsey was given authority, as the USAF's Chief of Safety, to investigate the circumstances which led to this crash. His findings were released to the Department of Defense but not the general public. A separate investigation, called AFR-110-14, was released to the public in 1995, and the findings are disturbing.

The accident board stated that Bud Holland's personality significantly influenced the crash sequence. USAF personnel testified that Holland had developed a reputation as an aggressive pilot who often broke flight-safety and other rules. 

What follows are some testimonials and stories from 1991-1994 regarding Holland's behavior and performance:

1. An incident occurred in 1991 when a B-52 piloted by Holland performed a circle above a softball game in which Holland's daughter was participating. Beginning at 2,500 feet (760 m) AGL, Holland's aircraft executed the circle at 65° of bank. In a maneuver described by one witness as a "death spiral," the nose of the aircraft continued to drop and the bank angle increased to 80°. After losing 1,000 feet (300 m) of altitude, Holland was able to regain control of the aircraft.
2. During a 19 May 1991 air show at Fairchild, Holland was the command pilot of the B-52 aerial-demonstration flight. During the demonstration, Holland's aircraft violated several safety regulations, including exceeding bank and pitch limits, flying directly over the air-show spectators, and possibly violating altitude restrictions. The base and wing commander, Colonel Arne Weinman, along with his staff, observed the demonstration, but apparently took no action.
3. On 12 July 1991, Holland commanded a B-52 for a "flyover" during a change-of-command ceremony for the 325th Bomb Squadron at Fairchild. During both the practice and the actual flyover, Holland's aircraft flew at altitudes below 100 feet (30 m) – well below the established minimum altitude – flew steeply banked turns in excess of 45°, exceeded pitch-angle limits, and executed a wingover. The wingover was not specifically prohibited but was not recommended, because it could damage the aircraft. After witnessing the flyover, Colonel Weinman and his deputy commander for operations (DO), Colonel Julich, orally reprimanded Holland, but took no formal action.
4. During the 17 May 1992 Fairchild air show, Holland was again the command pilot of the B-52 aerial-demonstration flight. During the demonstration, Holland's aircraft again violated several safety regulations, including several low-altitude, steep turns in excess of 45° of bank and a high pitch angle climb, estimated at over 60° nose high which Holland finished with a wingover maneuver. The new wing commander, Colonel Michael G. Ruotsala, apparently took no action. One week later, the new DO, Colonel Capotosti, on his own initiative warned Holland that if he violated any more safety regulations, Capotosti would ground him (remove him from flying status). Capotosti did not document his warning to Holland or take any other kind of formal action.
5. On 14 and 15 April 1993, Holland was the mission commander of a two-ship training mission to a bombing range near Guam in the Pacific Ocean. During the mission, Holland flew his B-52 closer to the other B-52 than regulations allowed. Holland also asked his navigator to videotape the bombs falling from the aircraft from inside the bomb bay, also against regulations. Holland's navigator later brought the video to the attention of three Fairchild USAF officers. The first, Lieutenant Colonel Bullock, the current 325th Bomb Squadron commander, did not do anything about it and may have even tried to use the videotape as leverage to coerce the navigator into accepting a position as mission scheduler for the wing. The second, the deputy operations group commander, Lieutenant Colonel Harper, told the crew member to conceal the evidence. The third, the DO, allegedly responded to reports of the video by stating, "Okay, I don't want to know anything about that video—I don't care."
6. At the 8 August 1993 Fairchild air show, Holland once again commanded the B-52 demonstration flight. The demonstration profile once again included bank angles greater than 45°, low-altitude passes, and another high pitch climbing maneuver, this time in excess of 80° nose high. The climb was so steep that fuel flowed out of the vent holes from the aircraft's wing tanks. The new wing commander, Brigadier General James M. Richards, and the new DO, Colonel William E. Pellerin, both witnessed the demonstration, but neither took any action.
7. On 10 March 1994, Holland commanded a single-aircraft training mission to the Yakima Bombing Range, to provide an authorized photographer an opportunity to document the aircraft as it dropped training munitions. The minimum aircraft altitude permitted for that area was 500 feet (150 m) AGL. During the mission, Holland's aircraft was filmed crossing one ridgeline about 30 feet (10 m) above the ground. Fearing for their safety, the photography crew ceased filming and took cover as Holland's aircraft again passed low over the ground, this time estimated as clearing the ridge line by only three feet (1 m). The co-pilot on Holland's aircraft testified that he grabbed the controls to prevent Holland from flying the aircraft into the ridge while the aircraft's other two aircrew members repeatedly screamed at Holland: "Climb! Climb!" ---(these accounts are taken from Wikipedia.)
8. The last event was the crash on June 24, 1994.

The accident investigation concluded that the crash was primarily attributable to Holland's personality and behavior, USAF leaders' inadequate reactions to the previous incidents involving Holland, and the sequence of events and aircrew response during the final flight of the aircraft. Holland's disregard for procedures governing the safe operation of the B-52 aircraft that he commanded and the absence of firm and consistent corrective action by his superior officers allowed Holland to believe he could conduct his flight in an unsafe manner, culminating with the slow, steeply banked, 360° turn around the control tower.

But there is far more to this story. Holland was the Chief of the 92d Bombardment Wing Standardization and Evaluation Section at Fairchild Air Force Base. This position made him responsible for the knowledge and enforcement of academic and in-flight standards for the wing's flying operations. He was regarded by many as an outstanding pilot, perhaps the best in the entire B-52 fleet. He was an experienced instructor pilot and had served with the Strategic Air Command's 1st Combat Evaluation Group (CEVG), considered by many aviators to be the "top of the pyramid". Selecting an aviator who exercised poor airmanship as the Chief of Standard and Evalulation's was a poor choice, but leaving him there after multiple flagrant and willful violations of regulations sent an extremely negative message to the rest of the wing flyers.

Individuals who hold key positions are looked up to as role models by junior crew members. They must be removed if they cannot maintain an acceptable standard of professionalism. Even if Holland had not crashed, the damage he had done through his bad example of airmanship is incalculable. Not only did many young officers see his lack of professionalism as a bad example, but they also observed several senior leaders witness his actions and fail to take any corrective action.

Prior to the accident, Holland and the rest of his flight crew, who were professionally at odds, were to be paired in the cockpit for the next several months. One of the crew members had confided in his wife that he did not trust Holland to fly with his aircrews. 

What is not mentioned in any of these accounts is the 'culture' which allowed this pilot to continue to fly, despite the evidence he was unsafe. In medicine, as physicians, we are often in charge of 'policing' ourselves when we see poor, inadequate or frankly, negligent care of a patient. But how often do we actually intervene if we are a trainee or subordinate?

Medical culture is very similar to military culture, which is why I want to point out the sequence of events which led to this tragedy. In medicine, as in the military, there is a 'chain of command.' For example, the attending is responsible for the fellows, chief residents, junior residents, interns and finally, medical students.

There is a clear distinction between each trainee and the level of responsibility for each position. What do trainees who obviously see a 'superior' engage in willful misconduct or behavior do? It is a very difficult situation for the observer, not the one who is engaged in the behavior. It's exceptionally challenging if the individual is at the top of the chain of command--and in charge of 'safety,' like Holland was.

The Fairchild accident is unique in that Holland's superiors never intervened effectively. The junior pilots and officers could have and should have had the ability to express their collective concerns with someone in a position of authority above Holland--without fear of reprimand, but that's the rub. I am certain there was fear of reprimand from reporting a pilot who has a reputation of being 'the best.' Even 'the best' pilots and physicians will make errors from time to time. But Holland repeatedly violated safety and protocol, and there is a big difference between an occasional mistake and a repeated pattern.

In my last article on managing professional behavior, I pointed out that some problem physicians often engage in repeated behaviors which represent a 'pattern.' The solution is simple. You create hard lines in the sand they can no longer cross and if they do, they lose their privileges. Corrective action is not an option because patient safety trumps everything.

Holland's commanding officers had a responsibility to report and document the discussions--and after the second incident, he should have been grounded. Yet, the 'discussions' were either not documented or there was 'no action' taken. We have a responsibility to first create and maintain a safe environment for the care our patients receive--and there should never be a compromise due to a complacent 'culture.'

At the conclusion of the investigation, the US Air Force circulated the findings of this accident throughout the rest of the service as a reminder of the importance of adhering to both safety regulations and maintaining an open 'chain of command' responsible for enforcing and disciplining those who choose to ignore them.

As physicians, nurses and health professionals, in order to maintain a state of 'high reliability' and safety, we must be vigilant and responsible--our patients depend on it.

The opinions expressed in this article are solely my own.

Matthew Mazurek, MD