Fighter Pilot Keynote Speaker

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Motivational Speaker on Safety: The Chain of Events Leads to the Scene of the Accident

In 1990, I was a first lieutenant, and had just finished Air Force undergraduate pilot training; I had been to F-4 Phantom School and was assigned to my first active operational squadron, where I flew the F-4E model. At this time, I had accumulated around 350 hours in the airplane and was still considered a “low time” pilot.

I was a hard charging young lieutenant, and I came into the squadron that morning, as I did every morning, looking for “holes” on the schedule. There were typically 4-8 airplanes in the morning lineup and 4-8 crews to fly them. If one of the pilots cancelled, there would be a “hole” on the board that I would be all too happy to fill.

Sure enough, there was one open cockpit to join a tactical low-level mission that was to be flown in western Pennsylvania with a final target on a bombing range. I put my hand up and said, “I’ll fill that hole!” and the operations officer added me to the schedule as #4 in the four-ship.

My flight lead had spent the previous afternoon and that morning planning the mission with his wingmen and he handed out color copies of maps to each crew member for the low-level navigation portion of our sortie. Unfortunately, the color copier had broken three quarters of the way through the job, so the map he handed me was a black and white copy. While this copy would have been mildly sufficient for reading a word document written in fourteen-point font, it was a far cry from adequate to navigate a tactical low-level mission at over 500 miles per hour.

Nevertheless, we were out of time for other solutions, and the briefing was about to begin. I took the map and headed into our briefing room knowing that as a wingman my primary job would be to fly formation off my leader instead of navigating using an illegible map.

We briefed the mission, which was to head out to western Pennsylvania, rendezvous with a tanker to air refuel, fly a low-level ingress through the Appalachian Mountains, drop our BDU 33 practice bombs on the range, strafe some additional targets and fly home. This was a low-level route that I’d never seen before, and at that early stage in my career, I was qualified to fly it only as a wingman not as a flight lead.

When we walked out to our jets, I did my standard walk-around and pre-flight inspection to determine any potential safety issues. I rejected my first jet because of a mechanical abnormality that I found in the tail section of the right engine. I told my crew chief that I didn’t feel comfortable with the jet and was immediately assigned to the spare which was set up and ready to go in anticipation of such a contingency.

My second jet passed inspection. My Weapons System Officer, affectionately known as a WSO or back seater, and I strapped in, started up, and checked in on the radio with my leader. He and the other two airplanes had already taxied out and were holding short at the end of the runway ready to take off.  My flight lead responded, “#4, we’re going to go ahead and press out to the tanker.  Take off as soon as you can and come catch up to us.” I acknowledged his directions and continued with my before-taxi checklist.

I taxied down to the end of the runway and pulled into the arming area which fighter pilots affectionately refer to as “last chance.” I set my parking brake and put my hands in the air so that the crew chiefs could see that all was safe and that I would not manipulate the flight controls while they walked underneath the jet to check that all systems were in order and to arm my weapons. My adrenaline was pumping as I was eager to catch up with the group, fly a new low-level and successfully put my bombs on target at an unfamiliar bombing range.

As I waited for them to finish, another thought began to form in my head.  I started to remember the accident briefings in my US Air Force Pilot training classes, and the words of my wise instructor pilots who reminded me that airplane accidents were never the result of one single incident; rather they always occurred at the end of a sequence of events that many pilots should have seen would ultimately lead to a mishap.  Often the sequence of events from these accident reports started the night before a flight because the pilot had been in an argument with their significant other, or had been kept up all night by a crying baby.  In other cases, it was clear that the pilot was dehydrated before a mission, which was often compounded by drinking too many diuretic soft drinks and not consuming enough water.  In every case, the popular expression during these briefings was “three strikes and you’re out,” which essentially means that the pilots and the squadron leadership should have seen many accidents coming well in advance because the sequence of events was leading them down that path.

These memories awoke a quiet voice in my head that said:

“You know, this is interesting.  This is just like all those accident reports they briefed me on in pilot training. I come into the squadron. I get thrown in a briefing at the last minute.  They hand me a black and white map because the copier is broken – Strike One. I reject my first jet because of a mechanical problem. Now my wingmen have left me and I’m going to go fly a low-level I’ve never been on – Strike 2, possibly with a black and white copied map that I can’t read. This feels an awful lot like a chain of events that could lead me to Strike 3. I should probably slow down, check my adrenaline and make sure that no one gets hurt today.” On further reflection, I said to myself, “While I’m sitting here waiting to take off, I’m going to pull out my map and write down the radio frequencies and the navigational aids (TACANS) for all of the divert fields along my route in case I have a 3rd strike today.”

It took a few more precious minutes to get this done, but at that moment, my training was kicking in and I felt that this was time well spent.

I took off and rendezvoused with the air refueling tanker. I learned that my wingmen had already refueled and headed off on the low-level route. I slid into position below the KC-135 refueler and flew steady formation while the boom operator “plugged me” and topped off my tanks. Fifteen minutes later, I was full of fuel and ready to start my mission.

The skies were crystal clear, the fall foliage was in full bloom, and I couldn’t imagine a more beautiful morning to fly over the ridge tops and down the river valleys of Pennsylvania. My WSO was only slightly more experienced than I was. He was a young Captain and as excited as I was to head “down range.” As our navigator, he vectored me towards our initial check point. I was cleared to descend by ATC, rolled the mighty phantom on its back, pulled the nose to 60 degrees below the horizon and in less than a minute we had descended from 26,000 feet to 500 feet above ground level (AGL) to begin our low-level.

Our first few legs had us zorching along, flying fast and low, at 480 nautical miles per hour (or eight miles per minute) 500 feet above ground level. We were terrain-masking behind ridge lines to simulate avoiding radar detection as we ingressed to our target area.

We were on time, we were on track, and we were both in awe of our beautiful surroundings.  Twenty minutes into our mission, we made a sharp left turn that led us over a pristine lake that funneled us into a spectacular river valley with walls that rose up more than 1,000 feet on both sides. This was our final leg before identifying our target, and per our plan I dropped down to 300’ AGL, stroked up the afterburner and accelerated my mighty Phantom to 540 knots or nine miles per minute. I remember a feeling of pure joy knowing how lucky I was to have the privilege of flying this great airplane in such a beautiful place. With hindsight, I now refer to this feeling as euphoria…which turns out to be the kind of feeling you get just before something bad happens.

About 60 miles from our target, I suddenly felt and heard what I perceived at that time to be a loud explosion with a bright flash of white light. The euphoria immediately disappeared and though I didn’t have any idea what happened, I instinctively knew that my next few actions would be critical to my survival. The whole cockpit had gone white which limited my visibility, and it had become extremely loud inside which meant I couldn’t communicate with my WSO regardless of how adamantly I yelled into the internal microphone in my mask.

My training kicked in immediately and once again my instructor’s key phrases hit me like a lightning bolt:

“Climb to Cope” – I immediately pulled the nose up to 45 degrees to get away from mother earth who would be unforgiving at my current velocity. Healthy spacing from the ground would inevitably buy me a little more time to figure out what had gone wrong.

“Speed is Life” – I parked both throttles in the northwest quadrant and lit my afterburners to make sure that we had as much potential energy as possible should we need to glide to a safe landing area or ejection zone.

“Analyze the Situation and Take the Appropriate Action” – My brain was racing, and while I still hadn’t figured out what had gone wrong, I knew we had a major emergency. I looked at my map, and picked out the nav-aid and radio frequency I had written down in the event that something went wrong during this portion of the mission. The nav-aid pointed me towards the closest airfield where we might be able to land. I squawked 7700 on my IFF transponder and tried to declare an emergency with air traffic control.

“Wind Your Watch” – My instructors had taught me that once I had the initial situation under control, it was always best to take a minute to “wind your watch and analyze the situation before taking further action.” By now we were pointed at a safe airfield about 90 miles on my nose, and were 20,000 feet above the ground. We were accelerating through 450 knots, and it was so loud I still could not communicate with my WSO or air traffic control. I leveled off, pulled the throttles out of afterburner and took a deep breath to try and figure out what was going on. I figured out that while the airplane was still flying, going fast made things even louder, so I pulled back my throttles, slowed the jet down below 300 knots and the noise started to diminish. Knowing that speed was life I cautiously slowed below 250 knots and suddenly I could begin to communicate. I once again declared an emergency with air traffic control and told them we would plan to land at a regional airport with a long runway that was now 50 miles on our nose.

Heart still pumping at 180 BPM+, I yelled over the intercom to my WSO, “Are you OK?  What happened?” He yelled back: “I’m OK. I think we hit some power lines!”

I thought to myself , ‘That’s impossible,’ then I realized that it wasn’t only possible but it was likely. He added “I’m not sure how to tell you this, but it looks like you shattered the back half of your canopy, and the drogue chute from your ejection seat is flapping out the side of the airplane all the way back to the tail section.”

This new bit of information gave me great cause for concern. Though I didn’t understand how it had happened, if my canopy was badly damaged and my drogue chute from my ejection seat had deployed, I feared the power lines had started the ejection sequence and at any minute the ejection seat rocket that I was sitting on would try to go up the rails, smash into my broken canopy, and I would meet my maker like Goose did in Top Gun.

“Fly the Airplane First” – With my ejection option ruled out, I realized that I had only one choice and that was to land my trusty Phantom as gingerly as possible and hope that I wouldn’t cause the ejection sequence to continue. With all the real and potential damage to my airplane, I was worried about the airworthiness of the jet at the slow speeds needed in order to touch down safely.  My WSO and I ran a controllability check above 10,000 feet. I lowered the gear and flaps, slowed to a safe landing speed, and low and behold our unbreakable beast kept flying.

This was all the encouragement I needed to continue our approach to land. I used every ounce of discipline to force myself to remain calm and execute our normal landing checks knowing that at any moment something could go terribly wrong. I touched down ever so gingerly on the 10,000-foot-long runway, pulled my drag chute and let out a huge sigh of relief as I slowed my wounded jet to taxi speed.

I pulled off the runway and was immediately greeted by fire trucks who looked me over to make sure that I was not on fire or leaking fluids.  I was then directed to pull onto the ramp of an Air National Guard unit that was based on the field.  I stopped on their ramp, which happened to be right near the approach end of the commercial airport runway. I signed off with ground control and radioed the command post of my new hosts: “Command Post, I’m the F-4 emergency aircraft who is parked on your ramp. We’ve got a badly damaged jet and a potential problem with the ejection seat. I’d like you to patch me through to the command post at my home base.”

They were eager to help and quickly patched me through via radio relay back to my home squadron.  I shared my status and current dilemma with the ejection seat. I asked them to send out a life support crew to help get us out of the airplane. They assured me that they would contact our life support team and fly them out to help ASAP.

In an attempt to satisfy some obscure safety requirement, the F-4 was equipped with a small knife inside the cockpit called a canopy breaker tool. This little shiv was hypothetically designed to help a pilot who was trapped inside the cockpit break the canopy glass and safely evacuate.

Feeling like I was strapped on top of a loaded cannon, I pulled the pin that held my canopy breaker tool in place. As I had been taught in flight school, I put one hand under the butt and firmly struck the canopy above me with the hope that I would shatter the glass and safely exit my crippled jet. Unfortunately, the canopy would have none of this and my knife bounced off of it as though I were using a piece of greased balsa wood.  I tried numerous different angles and techniques with no success and eventually worked myself into a full lather with a number of choice words for what I was now calling the “canopy bonker tool.”

So there we were, stuck on the ramp with a shattered canopy, a drogue chute flapping down the side of our jet, and nothing to do but wait for my ejection seat to fire or my life support crew to save us. We sat on that ramp for over two hours in the hot sun. Several airliners pulled up next to us as they held short for departure that morning. We kept our visors down on our masks as we could see the passengers faces pressed against the window wondering what the heck happened to those guys? Eventually our life support team arrived to save us. We shut down the airplane and let them take over. They had a much larger canopy breaker tool (think fireman’s ax) which they used to shatter my canopy from the outside and extract me from my cockpit.

My squadron commander flew out, for a full Debrief and put me up in a local hotel that night. Over the course of the next couple of days, my squadron and the USAF conducted a thorough safety investigation and Debrief of the incident and the series of events leading up to it. As it turns out, we had flown through a field of power lines 389 feet above the ground in a river valley. If there was good news, it was that I survived the encounter and we were legal to fly down to 300’ above ground level, so we weren’t in violation of any rules. I never saw the power lines visually, and upon further review, they were nearly impossible to identify on the grainy black and white copy of the map that I had been carrying in my jet that day. I hit the power lines at about 550 miles per hour and they ran up the nose of my airplane, compressed my canopy until it shattered above my head and even cracked my helmet. That power line was also the line that scraped on the top of my ejection seat and released the drogue chute. The line finally snapped off on the metal section of the jet that separated my cockpit from my WSO’s at his nose level.

The other three power lines continued to run down the back of the airplane and eventually snapped off on the vertical stabilizer after ripping through the airplane’s skin. There is no doubt in my mind that my helmet and the well-designed F-4 Phantom saved my life that day, and I feel lucky to be here to retell this story.

As part of the safety investigation, the next day we flew back to the scene of the accident in a helicopter and hovered right in front of the powerlines at the same time of day in order to get a better understanding of why I had not seen this hazard. Even at a dead still hover less than 100’ from the power lines, I was unable to visually identify the lines because the sun was hitting them in such a way that they were invisible to me and the rest of the crew.

In the end, the Air Force classified my incident as a Class C accident, because there was less than $100,000 of damage to the jet and no loss of life. A class B accident involves $100,000 or more of damage to the aircraft, and a Class A accident involves a loss of life or a loss of the airplane.

The accident investigation board found that I had not violated any Air Force regulations or civilian flight rules and they commended me on the handling of the emergency after impacting the power lines. With that said, no one, especially me, was happy that the incident had occurred, and it was a powerful reminder of the inherent dangers of tactical aviation and the telltale signs that a sequence of events often leads to the scene of an accident.

I personally gleaned a number of additional lessons from that day which I have continued to practice in my aviation and professional life.

Lesson #1:  Training is Critical

The Air Force training’s constant emphasis on safety makes all of its pilots better and safer. The fact that all accidents are thoroughly investigated and that the findings are shared globally with every squadron in the force gives our fraternity of aviators the opportunity to learn from the mistakes of others and identify the sequence of events that could get them in trouble in the future. Even though I thought it could never happen to me, my training kicked in as soon as the sequence of events started to unfold on my mission. My instructor’s words of wisdom were ringing in my ears and compelled me to write down the radio frequencies and the navigational aids that ultimately allowed me to quickly point my aircraft to a safe field and get us on the ground. When crisis hit, even though I didn’t know what happened, the muscle memory from my training went into overdrive and my instructor’s mottos of “climb to cope,” “speed is life” and “aviate, navigate, and communicate” kicked in and guided me in my recovery from a life-threatening situation.

I often ask companies I work with how much time and energy they put into the formal training of their people versus the well known on-the-job training that so many of us have experienced in the corporate environment. I also encourage them to put special emphasis on emergencies, whether it’s a customer complaint, a key employee leaving for a competitor, or a fire in a manufacturing plant. Training your people to handle these emergency situations the right way the first time ensures safe solutions and prevents your team from compounding bad situations.

Lesson #2:  The Team Succeeds or Fails Together

Our squadron conducted an accident investigation following the incident, and identified several root causes associated with my accident:

  • Flying with black and white maps
  • Sending a young lieutenant to fly solo down a low-level route in an area he had never flown
  • Inadequate briefing on potential threats and hazards along the low-level route
  • Flight rules allowing flight down to 300’ AGL on a route with significant hazards below this altitude

Just to be clear: I hit those power lines, and I was ultimately responsible for what happened to us on our mission. But the Air Force believes that in another sense, every member of the supporting team was up in that plane during impact.

They were there in the form of maps that had been hastily copied, a color copier that had been improperly maintained, rules that had been put in place, leadership and procedural decisions that had been made that day. This approach does not eliminate my responsibility as the pilot for the safe conduct of my flight, but it creates a culture that analyzes the root causes of this accident and asks what can we do as a team to prevent something like this from ever happening again.

In many ways, a sales meeting is a lot like a flight mission. The Sales Rep is the flight lead and always receives the praise or blame when a deal is won or lost, even though the ultimate outcome impacts the entire company. From the person in order entry who handled a previous order, to the people in accounting processing accounts payable, to the operator who answers the phone at headquarters – everyone is involved in that sale and everyone can have an impact on the customer’s experience.

Lesson #3: Developing a culture of open and honest Debrief accelerates the experience of all

When our accident occurred, the Air Force didn’t start a witch hunt, they started a Debrief and a safety investigation which assumed that I was a well trained, hardworking fighter pilot doing my best to accomplish my mission. Starting with this perspective in mind turned the investigation from an exercise where I was trying to defend myself to one in which we were all trying to figure out what happened and how we could learn from it. In all fairness, if it had been discovered that I violated USAF or civilian regulations, the tone of our Debrief might have changed. But I felt that the investigators believed in me and had my best intentions at heart which led me to share openly on my thoughts and actions leading up to the crash. Their findings were also shared openly with my squadron mates and other pilots to help them avoid making the mistakes I had made on that fateful day.

I feel lucky to be alive following our power line incident so many years ago, and I still keep my cracked helmet to remind me to watch out for the sequence of events that can lead to disaster. Thanks to the Air Force’s emphasis on safety training, methods, and processes, over the next 18 years I went on to accumulate thousands of hours in the F-4 Phantom as well as the F-16 Falcon, and I never stopped learning from my own mistakes and the mistakes of others. I have applied many of these same lessons to my business career and that has made all the difference between failure and success.

13 thoughts on “Motivational Speaker on Safety: The Chain of Events Leads to the Scene of the Accident

  1. Thank you for sharing Anthony, amazingly written. I will share with others. Hugs to Mary and the rest of the fam!

  2. AB, thanks for sharing and love the lessons learned here. Nothing replaces training and preparation for sure.

  3. Good stuff and lots to be learned from your experience. Thanks so much for sharing.

  4. Riveting story and great lessons. Thanks for sending.

  5. another incredible experience of yours I’m grateful to hear about, thanks AB.

  6. AB; thank you for a great recount of a very instructive sequence of events.
    It clearly demonstrates that military disciplines and protocols apply to the business world.
    Having been the beneficiary of your coaching I do reflect before action, an attribute that had not been previously my way of operating.

  7. You first told me that story over a decade ago, but its impact has not lessened with time. Glad you made it AB.

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