Human Factors Analysis of June 24, 1994 – B-52 Crash

On June 24, 1994 Lt. Col. Holland was practicing maneuvers for an air show. While executing a "go-around" at 250 feet altitude, the plane stalled and fell out of the air.

For the vast majority of humanity, learning, and therefore changes in behavior often only occur as the result of events or other occurrences that produce concrete evidence illustrating the problem. Consider for example the way aviation accidents in general have shaped the present day procedures and attitudes of aviation. This is clearly an example of reactive changes, or changes in reaction to events. For the most part, humans operate in this mode. Doctors advocate preventative measures to maintain health, but even those are is in response to concrete data indicating the negative effects of an alternate course of action. Engineers seem to be one of the only groups that attempt to aggressively solve imaginary problems before any mention of the problem has occurred for the first time.

This method of how we as humans learn and advance is in some part to blame for our trouble in diagnosing the hot stick cowboy pilots and removing them from the air. I believe the real problem is separating the personality of a person from their actions. In the case of a cowboy pilot captain, the first officers may not want to fly with him/her because of incompatible personalities, and not dangerous flying. There may also be a conflict because the cowboy pilot has a different approach to solving problems, again not necessarily indicating hazardous flying, but an alternate way of thinking.

As I stated above, change generally occurs as a result of concrete evidence. The problem of removing the cowboy pilot from the air will generally only occur once concrete evidence is available indicating they are a hazard whether it is something on a CVR, or a resulting accident.

In the case of the crash of a B-52 on June 24, 1994, we can only guess that that no one in a position to resolve the problem actually believed that Lt. Col. Holland was a hazard. Today, after the tragic accident it’s easy to say that Holland was a hazard and point to his long history of incidents. The real question is on June 23^rd (the day before) was he viewed to be a hazard by his superiors, or was he looked upon as a “super pilot” of legend?

Let’s put ourselves at Fairchild Air Force Base on June 23^rd. You’re introduced to Lt. Col. Holland, a 23 year veteran of the Air Force perhaps who has flown 26,000 hours in the B-52, flown hundreds of combat missions, perhaps is a decorated soldier. This pilot had flown the B-52 well beyond the limits of it’s envelope for pitch and bank, and performed aerobatic maneuvers with the B-52. He has been cited for violating a regulation about flying over an air show crowd, and flying close formation for photos. He also had an incident in which one pilot states he almost hit a ridgeline – but that incident is his word against the other pilot’s. From that introduction what would you think about Lt. Col. Holland? Dangerous, or a living legend? I think that many people probably viewed him as the later.

My guess is that his position and tenure combined with the structure of the Air Force made it very difficult for him to be grounded by anyone unless they were very sure, and they had concrete evidence to back up their decision which they apparently did not. I think the prestige of his tenure and rank also resulted in other crewmembers looking the other way. Since there were no tangible results of his hazardous attitude, there was nothing concrete by which to raise attention to the matter. This combined with the culture of the military where people are told to follow orders by superiors resulted in fellow crewmembers looking the other way.

It was this combination of rank, military culture, tenure, lack of physical evidence indicating he was a real threat that allowed him to continue to fly in air shows. Should the Air Force have responded earlier to incidents? Absolutely, but that is not the way the Air Force works. Just by watching the news coverage of the rape scandals at the Air Force Academy we can clearly see that the Air Force, and government in general is not rapid, progressive or preemptive in the resolution of any problem of any kind. This is partially to blame on the culture of the military combined with the way in which humans learn only from mistakes. Even then, the Air Force will require that the lesson be repeated multiple times before changes will be made.

The reality is that our race predominately advances itself by learning from our previous mistakes. We seem to only introduce systematic control into processes that have failed, and if a process has not yielded any negative results it is deemed to be acceptable. This concept has resulted in a great many tragedies. Someday, perhaps we will learn to be preemptive in our quest for a safer and better functioning world. This concept has universal application in any endeavor where the stakes are high. Human in general need to be more proactive rather than reactive, and even then, unavoidable events will occur to teach us what we didn’t know before.

See Also

• Darker Shades of Blue
  This is an interesting analysis and paper on the same incident.