Conclusions from the Friendly Fire Example

When looking only at the proximate events and the behavior of the immediate participants in the accidental shootdown, the reasons for this accident appear to be gross mistakes by the technical system operators (the pilots and AWACS crew). In fact, a special Air Force task force composed of more than 120 people in six commands concluded that two breakdowns in individual performance contributed to the shootdown (1) the AWACS mission crew did not provide the F-15 pilots an accurate picture of the situation and (2) the F-15 pilots misidentified the target. From the twenty-one-volume accident report produced by the Accident Investigation Board, Secretary of Defense William Perry summarized the errors, omissions, and failures in the chain of events leading to the loss as  

According to Snook, the military community has generally accepted these four causes as the explanation for the shootdown. 

STAMP views an accident as a dynamic process. In this case. Army and Air Force operations adapted and diverged without communication and coordination. OPC had operated inddent-liree for over three years at the time of the shootdown. During that time, local adaptations to compensate for inadequate control from above had managed to mask the ongoing problems until a situation occurred where local adaptations did not work. A lack of awareness at the highest levels of command of the severity of the coordination, communication, and other problems is a key factor in this accident. 

More information on how to build multiple views of an accident using STAMP in order to aid understanding can be found in chapter 11. More examples of STAMP accident analyses can be found in the appendixes. 

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