Blame vs. Cause


Naval Aircrewman (Helicopter) 3rd Class Justin Ricciuti, ensures an MH-60S Sea Hawk helicopter assigned to the “Sea Knights” of Helicopter Sea Combat Squadron (HSC) 22 maintains safe flight operations during a vertical replenishment. Photo by Mass Communication Specialist 1st Class Scott Bigley.

In the halls of the Naval Safety Center, I hear this all the time, “Should we blame the pilot or the procedure?” During our “round table” safety investigation report endorsement debates in the aviation shop at the Naval Safety Center, we do not use the word “blame.” Blame indicates a pilot, NFO, aircrew, maintainer, CO, Ship’s CO, Commodore, CAG, MAG, Admiral, or General is responsible for the outcome or the events leading up to a mishap. It usually means they will be held accountable for their actions. Blame has a very real place in today’s Navy and our society as we have seen in Seventh Fleet incidents, but it has no place in an aviation mishap safety investigation. One of the objectives of the Aviation Safety Management System, OPNAV 3750.6S, is to investigate and determine cause so that we can learn from past incidents and prevent mishap recurrence.

When addressing blame, we can consider the third principle from the Navy’s Charge of Command – accountability; which is the process through which we hold military members accountable for their actions. The Uniform Code of Military Justice (UCMJ) covers the rules and regulations expected of military service members. There are multiple current cases where Commanding Officers are facing court martial for mishaps that have occurred within their commands. It is specifically addressed in the charge of command; you must “accept the extraordinary responsibility of Command with full regard for its consequences.” Accountability (or blame) addresses the individual’s actions and is not directly meant to help others learn from the individual’s mistake.

Since this is a non-privileged forum, I will bring up a hypothetical incident. In my junior officer days flying the mighty SH-60F anti-submarine warfare dipping helicopter, we would constantly prepare for a scenario where the aircraft would have a single engine failure while in a dip. Imagine the dipping SONAR is being streamed. The aircraft has a #2 engine failure as a result of internal engine FOD.

The aircraft is now single engine, in a 70-foot hover rapidly losing altitude. The pilots elect to cut the dipping SONAR and fly away using all power available from the good engine. We did not have Integrated Maintenance Data System (IMDS) on the legacy H-60, but now we do. Say the IMDS software picks up an Ng exceedance that requires removal and replacement of the good engine. The pilots safely fly away the aircraft and recover as soon as practical at NAS North Island. Did we have a mishap?

Paragraph 306b of OPNAV 3750.6S covers the intentional jettison of dipped SONAR systems when the reason is not malfunction. Paragraph 306e covers the #2 engine failure as a result of internal engine FOD. Now, as a result of the pilots’ actions, to safely fly the aircraft away from the water, they had to “torch” the good #1 engine. The IMDS says you have an exceedance that requires engine replacement in case you were focused on keeping the aircraft out of water. Do we have a mishap? The answer is yes. There is no mishap exception for damage to other aircraft components as a result of an internal FOD engine failure. You must now investigate this mishap. The #1 engine is repairable so you apply the 15 percent rule plus man-hours required to remove and replace the engine at the O-level. The overall cost of the reportable components from the mishap is $103,892, which is a Class C mishap.

It is your duty as an aviation mishap board member to determine the causes of the mishap. Causes are determined so we can make recommendations to mitigate risks during current operations and prevent future mishap occurrences. Are there any human factors associated with this mishap? I would say yes. Mishap pilots caused Ng exceedance requiring engine replacement. It does not matter that the initial material failure of internal engine FOD began a series of events that led to the pilots overstressing the good engine.

The pilots definitely should be commended for saving an aircraft and aircrew, but they still can be found causal in the mishap. This is critical. The pilots and their actions can be the single most heroic incident since Clementine Two rescued downed aviators after colliding with a tree in Vietnam and flew a damaged helicopter back to the boat. In the Clementine Two case the pilots’ actions of flying into a tree caused the mishap. It doesn’t matter that the action was the right choice. I think we can all agree Clementine Two made the right choice, but the mishap action is still causal. In case you don’t agree they received the Congressional Medal of Honor for their actions. Cause determines what happened and what we can do to prevent future mishaps. In this case, it may lead to building a better engine contingency power system or a collision avoidance system. Mishap recommendations are for the safety of those that are left behind that need to learn from the incident.

Blame is for holding individuals accountable for their actions. Blame is reserved for the individual and needs to stay out of safety investigations and endorsements.


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