Military Accident Investigations Are Essentially Incestuous

Aviation accident investigations in the civilian world are models of independence and scientific objectivity compared to the practice in the U.S. military. In the armed forces, accident investigations are conducted by the parent command; in other words, the outfit that set policies and procedures – or failed to do so – convenes an investigation on itself. This is analogous to an airline conducting an investigation of a crash of one of its airplanes. Such a scenario is rife with the possibility for cover-up, blaming of subordinates, overlooking failures higher up, suppressing technical or human factors issues, you name it.

Alan Diehl argues that it’s time to create a separate accident investigation body outside of the Defense Department analogous to the National Transportation Safety Board (NTSB). He should know. He’s got experience as an accident investigator with the NTSB and, later in his career, as a staff investigator with the Air Force Safety Agency. Now retired, he was in a unique position to compare the fundamentally honest independence of NTSB investigations with the fundamentally incestuous practice of self-investigation in the military.

First, a little history; in 1974 Congress made the NTSB independent of the Department of Transportation (DOT) because of the obvious difficulties allowing any organization to investigate itself. In 1994, Congress also closed a loophole that allowed most government departments to investigate their own crashes. Unfortunately, the Defense Department was excluded from this law.

The result is a cumulative toll of loss that exceeds that of destroyed aircraft and dead pilots in combat. In his 2007 book, Silent Knights, about the history of botched military accident investigations, Diehl recounts the toll:

  • Over $50 billion in reported economic losses. The real number is anybody’s guess.
  • More than 2,000 military aircraft destroyed, compared with less than 100 airliners. This comparison is apt because the military’s fleet of aircraft is about the same size as the nation’s current fleet of on-demand, air-taxi, commuter and scheduled airliners.
  • More than 15,000 military deaths in all accidents, compared with fewer than 600 from hostile action.

In 1991 (ancient history, but highly relevant because the situation is unchanged today), Brigadier General Joseph Hall, head of the Air Force Safety Agency, wrote the chief of staff of the Air Force a blunt letter. Among other things, it said:

“I have witnessed command manipulation of mishap cost/classification to improve the command statistics/image, shallow and incomplete investigation into mishap causes, interference by MAJCOM [major command] staffs with the investigative board process, and punishment of board members for unpopular findings … Even more troubling is the acceptance by senior leaders of a mishap investigation process which frequently obscures supervisory culpability … [The] investigative process has been politicized to the point of dysfunction.”

About a month later, BGen. Hall got a terse letter telling him to enjoy his retirement.

To this day, accident investigation in the Air Force (with similar arrangements in the Army and Navy) goes like this: the command that experiences an accident appoints members to its so-called Safety Investigation Board (SIB). Commanders never like surprises, so they ensure that the voting members of the inquiry are people they know and trust. These subordinates are line officers, such as pilots, who have nil training or experience in the protocols used by professional accident investigators.

SIB reports are supposed to be kept privileged and never released outside the Defense Department. The official purpose of the SIB report is to establish why the mishap occurred. But, the system is often abused to protect commanders from embarrassment and accountability.

To get around such criticism, the military services have commanders conduct another, separate investigation. This second type of inquiry is called an Accident Investigation Board (AIB). Its stated purpose is to establish legal responsibility, but its real objective is public relations. Basically, according to Diehl, the military has learned the value of keeping two sets of books on each mishap.

AIBs suffer many of the same problems as SIBs, namely, hand picked subordinates who are not trained, professional investigators. Unlike SIBs, witnesses who are interviewed by AIBs do not have immunity; understandably, witnesses are loathe to reveal information that later could be used to prosecute them. Further, these AIB reports will be released to the public, including the victims’ families, Congress and the press.

Consequently, these AIB reports are less informative than the SIB inquiries.

The difference between civilian and military practice may be summed up thusly:

Civilian: there is a legally mandated system of checks and balances, which feature well-established “fire walls” between different, critical domains, For example, the operators (airlines), the investigators (NTSB), and the regulators (the Federal Aviation Administration) are separate and independent from one another.

Military: these functions are merged into one all-powerful organization.

What’s needed, Diehl says, is the creation by Congress of a Military Safety Board (MSB). This new agency should be totally independent from the armed services and the Defense Department, with several major functions:

  1. Investigating mishaps and accidents involving military aviation, warships, tracked vehicles and trucks and issue recommendations to correct safety deficiencies.
  2. Perform special studies.
  3. Issue public statements on findings, causes and recommendations.
  4. Advise Congress and Defense Department officials on these matters.

These functions mirror those of the NTSB. The MSB would have the capability, staff and mandate to perform economic, operational and environmental impact studies. The NTSB does not have this function, but with this charter the MSB could examine such issues before making recommendations. This feature could reduce the number of “yeah, buts” – recommendations rejected by the Defense Department as unrealistic or not cost-effective.

The MSB would also differ from the NTSB in another important aspect. The MSB would operate an anonymous reporting system enabling those in the military to report hazards. Presently, the FAA utilizes the National Aeronautics and Space Administration to operate the Aviation Safety Action Program (ASAP), which enables pilots, flight attendants, air traffic controllers and mechanics to anonymously report safety hazards. For the armed forces, the MSB could fulfill this function, providing it with a means of detecting potential problems before they turn into catastrophes.

The MSB would not only professionalize accident investigation, it will protect line officers now filling AIB/SIB slots from capricious actions of their bosses.

The military’s two-tiered, self-serving and secretive system of AIBs and SIBs clearly does not work, as evidenced by the continuing high accident rate. During the last quarter century, operational accidents have actually killed ten times more service members than have been lost due to hostile action. One would think – and expect – that training for the fight would be inherently safer.

(Dr. Alan Diehl’s book, Silent Knights; Blowing the Whistle on Military Accidents and Their Cover-Ups, was published by Bristol Park in 2007. He can be contacted at