AIR UNIVERSITY

AIR WAR COLLEGE

Toward A Fail-Safe Air Force Culture

Creating a Resilient Future While Avoiding Past Mistakes 

TODD C. ERICSON

Lieutenant Colonel, USAF

Air War College

Maxwell Paper No. 66

Maxwell Air Force Base, Alabama

October 2012
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Disclaimer

Opinions, conclusions, and recommendations expressed or implied within are 

solely those of the author and do not necessarily represent the views of Air 

University, the United States Air Force, the Department of Defense, or any other 

US government agency. Cleared for public release: distribution unlimited.

The Maxwell Papers are available electronically at the Air 

University Press website at http://aupress.au.af.mil.
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Toward a Fail-Safe Air Force Culture:

Creating a Resilient Future While Avoiding Past Mistakes

Lt Col Todd C. Ericson, USAF

Col Steve Goldfein, commander of the 1st Fighter Wing, summed 

up his responsibility stating, “In the end, commanders do only two 

things—provide vision and set the environment. Almost everything you 

do for the organization falls into one of these categories.”1

Gen Ronald R. Fogleman, former Air Force chief of staff, inherited a 

series of such incidents when he took command. In response, he issued 

an August 1995 video tape on the topic of “Air Force Standards and 

Accountability.” The tape followed additional administrative actions he 

directed against officers involved in the 14 April 1994 shootdown of two 

US Army helicopters.

Unfortunately, 

it is often in the wake of incidents, tragedies, or failures that 

shortcomings are exposed.

2 In the immediate aftermath of this incident only 

one officer, the airborne warning and control system (AWACS) 

commander Capt Jim Wang, was court-martialed for the death of 26 

friendly personnel.3 Others involved, to include the F-15 pilots who 

actually shot down the helicopters, received nonjudicial punishments 

which were initially intended to remain outside of their permanent 

service records. In defending the additional punishments he levied, 

Fogleman argued the lack of initial accountability was an unacceptable 

failure of leadership.4 Significantly, this all transpired only a few months 
4

after Col William E. Pellerin’s court-martial in the notorious 24 June 

1994 crash of a B-52 at Fairchild AFB, Washington––a crash resulting 

from the actions of a rogue subordinate pilot, Lt Col Arthur Holland, and 

the lack of accountability exhibited by his senior officers.5

The inadvertent transportation of nuclear cruise missile warheads 

on a B-52 from Minot AFB, North Dakota and the shipping of nonnuclear 

intercontinental ballistic missile components to Taiwan are analogous 

contemporary events. Dr. James R. Schlesinger’s 2008 report to the 

secretary of defense documented atrophy in the Air Force’s nuclear 

enterprise as a primary cause for these failures. The report highlighted “a 

serious erosion of focus, expertise, mission readiness, resources, and 

discipline in the nuclear weapons enterprise within the Air Force.”6

Secretary of the Air Force Michael Wynne and Air Force Chief of Staff 

Gen T. Michael Moseley both resigned in the wake of these incidents, and

on 24 October 2008 the new secretary of the Air Force, Michael Donley,

and Air Force Chief of Staff Gen Norton Schwartz issued their “Strategic 

Plan to Reinvigorate the Air Force Nuclear Enterprise.”7 Notably, the 

strategic plan identified the establishment of a “zero-defect” culture as a

primary attribute for a successful Air Force nuclear enterprise, stating 

“there is no tolerance for complacency or shortcuts as we rebuild a ‘zerodefect’ culture.”8

Each of these incidents represents a catastrophic institutional 

failure—failures which must be prevented. Ceding the impossibility of 
5

omnipresence, Colonel Goldfein correctly observes that choice of vision 

and cultural development are leadership’s fundamental tools in building 

a successful organization. The cultural options available to espouse span 

a continuum from a ruthless zero-defects method to a gentler tolerancebased style. While a zero-defect approach can garner short-term success, 

the ensuing culture of fear and reprisal are not conducive to sustained 

excellence. Conversely, a tolerant approach may achieve short-term

morale benefits, but the resulting lack of discipline arising out of a 

culture of ambivalence dampens long-term productivity. Ultimately, longterm high performance is possible through a fail-safe culture which 

paradoxically embraces failure in building a resilient enterprise. Modern 

research on high reliability organizations (HRO), coupled with 

contemporary leadership theory, provide a framework to expose the 

shortcomings of both the zero-defect and tolerance-based approaches, 

assess current culture, and then define the cultural characteristics 

required to implement a mindful approach to ensuring the Air Force can 

achieve its mission by maximizing our ability to “fly, fight, and win . . . in 

air, space, and cyberspace.”9

Tolerance-Based Culture

A tolerance-based culture fundamentally embraces a Kantian belief 

in the inherent goodness of man and concludes that with proper 

guidance people will “do the right thing.” In this culture, empowerment of 

individuals and their ability to improve the system is primal while 
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discipline and external accountability are relegated to lesser roles. Its

ideal is the attainment of a self-policing workforce—one that corrects 

problems before they have the opportunity to amplify. The Air Force 

embraced such a system in the late 1980’s through the mid 1990’s, 

under the Quality Air Force (QAF) banner. QAF borrowed heavily from 

the Total Quality Management (TQM) work of Dr. W. E. Deming and 

asserted that TQM’s successful transformation of business practices 

could also transform the Air Force. Air Force Systems Command’s 1989 

implementation brief defined the QAF ideal as: “A leadership philosophy, 

organizational structure and working environment that fosters and 

nourishes a personal accountability and responsibility for quality and a 

quest for continuous improvement in products, services and 

processes.”10

The proposal was seductive as Deming’s plan, do, check, act 

(PDCA) cycle that transformed post-WWII Japanese industry paralleled

Col John Boyd’s famous observe, orient, decide, act (OODA) loop for 

military operations. Deeper analysis, however, reveals a fundamental 

difference. The subtle replacement of “decide” with “check” initiated a 

cultural shift away from leadership decisions to one where measurement 

of processes and metrics informed the proper course of action.

QAF transformed Air Force regulations into softer instructions and

replaced harsh inspections with gentler quality Air Force assessments 

(QAFA). Graham Rinehart summarized the impact to the force as “Airmen 
7

saw TQM as an abdication of leadership, especially when it combined 

with empowerment—another fine concept that became badly mangled 

and unrecognizable in the end.”11 The sentiment was echoed by Gen

John Jumper in a 2001 speech to the Senior NCO [noncommissioned 

officer] Academy three months prior to his selection as Air Force chief of 

staff. He bluntly stated, “But we went through a period in the decade of 

the ’90s where the Air Force lost some of its character as an institution. 

We once had a quality Air Force that was ruined by a concept known as 

Quality Air Force.”12 General Jumper continued, advocating that 

“‘quality’ was used as a substitute for leadership. It let words and 

slogans guide our behavior. Words like 'empowerment,' 'break down 

barriers.' We stopped mentoring our people. We lost touch with the fine 

art of chewing ass. An example of this is the Blackhawk shootdown. We 

screwed up with those F-15 pilots. The essential nature of our business 

is to gain and maintain air superiority by shooting down bad guys. When 

you visually ID [identify] an aircraft and shoot it down, and it's one of 

ours, you have failed in your primary mission. It's worse than a doctor 

taking out the wrong lung. Something should have been done.”13

Similarly, the Air Force also acknowledged its mistake in 

transforming regulations. The subsequent addition of the phrase,

“COMPLIANCE WITH THIS PUBLICATION IS MANDATORY,” on the cover 

of each Air Force instruction was designed to ensure personnel 

Justice 

had not been served.
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understood implementation was not optional. By the mid 1990s, QAF 

had fallen out of vogue, never obtaining the sweeping cultural change 

envisioned. Its legacy, however, survives in both the officer performance 

reporting (OPR) system14

AFSO21 strives to eliminate many of QAF’s deficiencies while 

simultaneously reinforcing its strengths. According to Air Force Material 

Command instruction (AFMCI) 90-104, Implementing AFSO21 Initiatives, 

“AFSO21 represents an Air Force model for continuous process 

improvement (CPI) that uses various methodologies depending on the 

needs of the situation or problem under review.”

and under the auspices of the Air Force smart 

operations for the 21st century (AFSO21) program.

15 The program has two 

stated goals: 1) “To fundamentally change the culture of the Air Force 

(AF) so that all Airmen understand their individual role in improving 

their daily processes and eliminating wasted efforts that add no value to 

mission accomplishment;”16 and 2) “To instill a mindset of continuous 

process improvement and problem solving across the USAF workforce.”17

Zero-Defects Culture

Compliance with this AFMCI is mandatory.

Contrast this cultural shift toward the middle following QAF with 

the nuclear enterprise’s renewed focus on a zero-defects culture. The Air 

Force’s history with Strategic Air Command (SAC) serves as an effective 

model for the implications of this policy. Despite corporate memories 

growing fonder over time, under Gen Curtiss LeMay SAC embodied a 
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ruthless culture of discipline. Folklore recounts the standard response to 

a failing inspection was General LeMay immediately flying to the 

unfortunate base with a replacement wing commander prior to the 

outbrief. Regardless of tale’s truth, its existence is illustrative of SAC’s 

culture. A security forces Airman assigned to SAC in the late 1980’s 

stated during an interview that his primary job (and that of his 

supervisor’s) was to pass inspections at all costs—outcome focus in 

response to ruthless discipline following past failures.18 Unfortunately, 

the long-term impact of this approach pressured honorable men to 

sacrifice their integrity in support of a zero-defects façade. Compelling 

testament is that the Airman, today a lieutenant colonel, remains too 

shamed by his actions to allow citing of specific details or his name.19

Objectively, how did SAC really compare to today’s denigrated

nuclear culture? According to the Department of Defense’s Narrative 

Summaries of Accidents Involving U.S. Nuclear Weapons: 1950-1980, 32

accidents involving nuclear weapons occurred during this time period 

resulting in the loss of at least 42 nuclear weapons or portions thereof.20

Most alarming is that six weapons were never recovered and that only 

four of these accidents (less than 10 percent) did not involve US Air Force 

aircraft, missiles, or assets.21 One of the most egregious of these 

accidents occurred on 22 May 1957 when a B-36 crew unintentionally 

dropped a nuclear weapon while on approach to Kirtland AFB, New 

Mexico. The weapon’s high explosives detonated upon impact, leaving 
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only a single safety procedure to prevent nuclear detonation.22

Jim Collins’ recent survey of companies in the book Good to Great

is one such study. His team found a very strong correlation between 

those corporations which significantly outperformed their competitors in 

the long-term and a “culture of discipline.” He observed of the highperforming entities “. . . they’re not ruthless cultures, they’re rigorous 

cultures. And the distinction is crucial. To be ruthless means hacking 

and cutting, especially in difficult times, or wanton firing people without 

any thoughtful consideration. To be rigorous, not ruthless, means that 

the best people need not worry about their positions and can concentrate 

fully on their work.”

While the 

lack of comparison data make it impossible to conclude what role a zerodefects culture played in these accidents, the data aptly demonstrate the 

inability of SAC’s zero-defects culture to prevent such accidents. 

Fortunately, comparative studies from the business world provide such 

data-driven analysis of cultural impacts on long-term organizational 

performance.

23 Conversely, he also discovered “. . . a pattern we 

found in every unsustained comparison: a spectacular rise under a 

tyrannical disciplinarian, followed by an equally spectacular decline 

when the disciplinarian stepped away, leaving behind no enduring 

culture of discipline, or when the disciplinarian himself became 

undisciplined and strayed . . .”24 In other words, tyrannical discipline

under a zero-defects philosophy produces short-term results.
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US Defense Secretary William Perry recognized this in 1996 when 

he criticized a zero-defects culture by remarking that “demanding such a 

rigid standard produces timid leaders afraid to make tough decisions in 

crisis, unwilling to take the risks necessary for success in military 

operations. This zero-defects mindset creates conditions that will lead 

inevitably to failure.”25 Weick and Sutcliff, authors of the book Managing 

the Unexpected, agree. They researched companies in fields similar to the 

nuclear enterprise and the Air Force in general—companies where the 

cost of failure is severe and where consistent, long-term, highly-reliable 

operations are essential. Despite these consequences, Karl Weick and 

Kathleen Sutcliff found that HRO’s embraced rather than suppressed 

failures. They observed “HROs encourage reporting of errors, they 

elaborate experiences of a near miss for what can be learned, and they 

are wary of the potential liabilities of success, including complacency, the 

temptation to reduce margins of safety, and the drift into automatic 

processing.”26

The long-term, sustained excellence demanded by the nuclear 

enterprise and the Air Force in general requires a shift to a new fail-safe 

approach that instills a culture of rigorous, not ruthless, discipline. This 

is a culture that recognizes the strengths and shortcomings resident in 

both zero-defects and tolerance-based approaches. Ironically, its

Instead of perpetuating the mindset that failure cannot 

occur, HROs not only accept that failures will occur but also structure 

themselves to prevent these failures from becoming catastrophic.
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template already exists and even thrives inside well-established Air Force 

organizations today.

Fail-Safe Culture

The concept of a fail-safe culture is straightforward. It begins with 

simply defining that which ultimately must be prevented. As with an 

aircraft, the designer’s ultimate goal is to ensure that his plane is 

capable of accomplishing its mission without loss of life or equipment. 

Analogous to an organization, mission constraints define the physical 

characteristics of the aircraft. Fighters differ from transports as the 

former require speed and maneuverability while the latter values range 

and payload. From a global perspective, the designer’s task is to create a 

system of complex mechanical and electronic systems which must 

operate in concert. Conceding that failure of components in each of these 

systems is inevitable during the aircraft’s service life, the designer must 

ensure that such a failure won’t result in a catastrophic crash. The 

resulting aircraft must be resilient, not perfect. And although all types 

are designed from within the same set of physical boundaries, mission 

requirements dictate that one size does not fit all.

Design resiliency is achieved by two means, the first proactive and 

the second reactive. The first seeks to improve the reliability of individual 

components and thus minimize the probability a failure ever occurs. 

Unfortunately, 100 percent reliability is not possible in parts conceived, 

designed, built, maintained, and operated by humans. Therefore,
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components are either inspected or replaced well prior to predicted 

failure, operational limitations are imposed, or procedural prohibitions 

are established. Secondly, reactive measures in the form of backups and 

redundancies are designed into a system on the assumption that the 

proactive measures are either insufficient or not all-encompassing. These 

measures are the designer’s hedge against the unknown. Thus both 

proactive and reactive methodologies work as an effective offense and 

defense against the ultimate catastrophic event. Aerospace engineers 

tout this as a fail-safe design approach.

Importantly, the fail-safe process does not stop at the initial 

design. Once in service, data from actual component failures, inspection 

results, and accident reports are fed back into the system. This data are 

incorporated as improvements in subsequent models, modifications to 

existing aircraft, or as changes to operations and maintenance manuals. 

A parallel process focuses on the operators and the two merge in our 

safety organizations. The Air Force safety system, guided by the precept 

of privilege or nonattribution, effectively reduced noncombat Class A 

accident rates (per 100,000 flying hours) from 44.22 in 1947 to only 0.80 

in 2009.27

In a fail-safe framework tolerance to each failure is defined by 

mission differences. An F-16, for example, was generally designed with 

sufficient backups to only allow it to safely return to base after a 

While impressive, the 62 years of data also demonstrate the 

Air Force’s inability to achieve a zero-defect flying program.
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failure—a conscious trade of mission capability rates for mission 

performance. A C-17’s mission, by comparison, demands backups that 

allow full mission capability in the event of a single failure. Likewise, the 

lack of a pilot alternatively increases an remotely piloted aircraft 

designer’s tolerance to failure (including crashes) as evidenced by lifetime 

Class A mishap rates (per 100,000 flying hours) over three times greater 

than equivalent manned aircraft—10.05 versus 2.89.28

Building a “Fail-Safe” Culture

While all of these

designs are fail-safe, their missions dictate different measures of merit in 

determining the appropriate design tradeoffs. The same is true of Air 

Force conventional, nuclear, space, and cyberspace missions.

How does this apply to the Air Force? First it is essential to define 

what must not be allowed to occur—catastrophic failures. At the Air 

Force level catastrophic failures represent anything which threatens the 

mission to “fly, fight and win . . . in air, space, and cyberspace” or its 

vision of “Global Vigilance, Reach, and Power.” Catastrophic cultural 

failure occurs when the Air Force’s core values of “Integrity first, Service 

before self, and Excellence in all we do” are compromised. Similarly, as a 

designer prioritizes aircraft traits based on mission, each command must 

define additional catastrophic failures based on its unique 

circumstances. For example, a top-level list for Global Strike Command 

(GSC) must include avoiding an accidental detonation of a nuclear 

device; Air Force Space Command must prevent total disruption of 
15

satellite communications and navigation services; Cyber Command must 

prevent an enemy from crippling our networks. A fail-safe approach 

asserts that while failure at lower levels is undesirable, these lesser 

failures must be embraced instead of feared since they are the greatest 

source of information about how to ultimately prevent the catastrophic 

failures. Potential failures are next ranked from most to least 

catastrophic with responsibility for each of the areas being placed 

squarely on the shoulders of a specific individual with commensurate 

authority. If responsibility and authority are diffused, it is not possible to 

justly hold people accountable for either preventing catastrophic failures 

or in the event they occur.

The Air Force safety process often uses the “Swiss cheese” model to 

evaluate accidents. The image of holes in the protective cheese layers 

(proactive and reactive measures) lining up in such a way as to allow an 

accident is extremely instructive. Conceptually, these protective layers 

represent expectations.29 Continuing the aircraft design analogy, an 

expectation that fly-by-wire controls will prevent an aircraft stall relies on 

an expectation the angle of attack system will provide the correct 

information. When either expectation doesn’t hold true, it is normally 

due to another failed expectation, such as the failure of a sensor. This is 

not to say that HROs aren’t concerned about each of the individual 

failures. They are, and certainly strive to minimize the number and size 

of holes in each slice of cheese. More importantly, however, a HRO’s 
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focus is on “the process of the slices lining up as each moment where one 

hole aligns with another represents a failed expectation. And each failed 

expectation is also an opportunity to stop the progression toward a 

brutal audit.”30

Generally, it is both daily operations and the inspection process 

which provide ongoing insight into the process of the holes lining up. 

Failures represent the opportunity for an in-depth analysis, but only if 

an organization embraces them and values a thorough and critically 

honest root-cause investigation. The logical conclusion of a zero-defect 

culture is that any failure during operations or an inspection, no matter 

how small, is unacceptable. Acceptance of this vision within GSC is 

evidenced by the recent firings of nuclear enterprise leadership at a rate 

far in excess of their conventional Air Force counterparts.31

Behavioral research across various fields supports the axiom that 

“perceptions are reality.”

Conversely, a 

tolerance-based culture’s lack of just accountability downplays the 

seriousness of failures and often discards valuable lessons.

32 Dr. Jack Kasulis and Dr. Robert Lush 

conclude from their study of business-customer relations that “in other 

words, perceptions are reality for the consumer regardless of objective 

reality.”33 Maria Sillanpää concludes from her research on effective, longterm corporate strategies that “for effective stakeholder inclusion, 

perceptions are reality. A misunderstanding is no less damaging to a 

relationship regardless of whether the company or the stakeholder is to 
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blame.”34

Rewards and Punishment in a Fail-Safe Culture

In forming the desired culture we must therefore be cognizant 

of the perception portrayed by actions and work to align those 

perceptions with reality. As leaders, these perceptions are initially set by 

our words and are ultimately confirmed or denied by our actions. These 

actions fall into one of two broad categories: rewards and punishment.

Experience bears out the timeless axiom, “You’ll catch more flies 

with honey than vinegar.” Positive rewards induce the desired behavior 

while punishment deters undesirable actions by setting boundaries on 

acceptable behavior. Recall that Collins found a very strong correlation 

between those companies which significantly outperformed their 

competitors and a rigorous “culture of discipline.”35

How? After defining the enterprises’ catastrophic failures, the next 

step is a continual assessment of the organization’s proactive and 

reactive design in support of these objectives. This is not a complete 

overhaul of existing procedures, regulations, or hardware, but is

conversely a mindful analysis of the existing design with an eye toward

evolutionary improvements. The essential input to this feedback process 

is information. And that information is inexorably linked to the 

organization’s culture through its people.

Instilling such a 

culture of rigorous, not ruthless, discipline is at the heart of a fail-safe 

organization.
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Weick and Sutcliffe observed HROs exhibit what they term a 

“Learning Culture,” one that adapts to changing demands and ensures

that people feel free and willing to discuss errors. This culture also

represents “‘an atmosphere of trust in which people are encouraged, even 

rewarded, for providing essential safety-related information—but in 

which they are clear about where the line must be drawn between 

acceptable and unacceptable behavior.’ That line is critical because it 

separates unacceptable behavior that deserves disciplinary action from 

acceptable behavior for which punishment is not appropriate and the 

potential for learning is considerable.”36 Similarly, Prof. Marc de Laval 

describes this desired culture as “an abandonment of the easy language 

of blame in favour of a commitment to understand and learn. It calls for 

significant leadership.”37

Exemplifying this rigor, the 416th Flight Test Squadron selected a 

team that highlighted a potential problem as the 1st Quarter 2010 test 

team of the quarter. They were selected not because they met an 

efficiency standard measured by the normal metrics of cost, schedule, or 

Although detailing how the Air Force cultivates 

these characteristics in a fail-safe culture is beyond the scope of this 

article, it already possesses at least three organizational benchmarks as 

templates: the flight safety process, the flight test community’s test safety

methodology, and the fighter community’s brief/fly/debrief cycle. All

exhibit high standards of discipline but also are extremely rigorous in 

learning from small mistakes as a means to prevent future catastrophes.
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performance as their actions both increased cost and further delayed a 

critical program already behind schedule. Why was such behavior 

appreciated? Because, despite cost and schedule pressures, they had the 

courage to make the right choice and the long-term positive impact on 

unit culture far outweighed the short-term losses. The award was a 

tangible demonstration of the unit’s emphasis on safety, proving that 

leadership embraced their rhetoric—actions speaking far louder than 

words.

Conversely, discipline serves the essential purpose of setting 

boundaries on actions in a manner analogous to how our pain response 

to a hot pan both minimizes the short-term burn and teaches us to avoid 

subsequent ones. Pain is therefore an essential tool our body uses to

prevent a bad situation from becoming dire. Likewise, punishment and 

consequences for actions are essential tools in defining acceptable limits 

of behavior inside an organization. Col William E. Pellerin was courtmartialed in the Fairchild B-52 crash because he, and others in 

leadership roles, failed to properly discipline Colonel Holland. Although 

Colonel Holland blatantly violated Air Force standards on multiple 

occasions prior to 24 June 1994, his leadership chose to ignore these 

“lesser” breaches of standards. Unfortunately, they and three other dead 

crewmembers of Czar 87 couldn’t ignore the catastrophic failure their

lack of discipline enabled.
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Beyond failure avoidance, implementation of consistent and fair 

discipline inside of well-established boundaries also bears the positive 

byproduct of instituting a sense of comfort and security within an 

organization. In a just organization, people have no fear of doing right 

and are comforted in the knowledge that doing the wrong will not be 

tolerated. They understand their boundaries. 

Justice in a Fail-Safe Culture

Col Dave Goldfein, in his book Sharing Success, Owning Failure,

asserts it is the commander’s responsibility to provide justice in 

discipline. When accomplished properly, he stresses, “Military discipline, 

handled with fairness, timeliness and compassion is always positive.”38

Our role as leaders is analogous to that of a parent as we strive to 

reinforce positive behaviors and work to effectively correct negative 

behaviors. World renowned parenting authors Gary and Anne Marie 

Ezzo,39 amplify Colonel Goldfein’s perspective stating, “The 

punishment/consequences must fit the crime. Punishment sets a value 

on behavior. That is why over-punishing or under-punishing is 

dangerous; both send the wrong message.”40

In the Blackhawk shoot down, it is precisely a lack of justice which 

led to General Fogleman’s and General Jumper’s conclusions. The initial 

minimal punishment received by the F-15 pilots for wrongly identifying 

and then killing 26 innocent personnel set an extremely low value on 

their negligence. By reaffirming the standards and levying a just 
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punishment for their actions, General Fogleman both recalibrated Air 

Force boundaries on expected performance and set an appropriate value 

on such an action. Consider the recent message sent by GSC leadership 

when three missile crewmembers were discharged from the Air Force 

after self-reporting they inadvertently slept while in possession of 

outdated classified codes inside a secure facility.41

Institutional justice is built upon a foundation of integrity, both 

personal and institutional. Maj Gen Perry M. Smith dedicates an entire 

chapter of his book Rules and Tools for Leaders to the subject. He insists 

that the first task a leader must accomplish upon taking over is vital—

ensure that the organization’s standards of integrity are clearly stated 

and articulated.

Is it reasonable to 

expect others will self-report future problems?

42 Once communicated, it is then essential for the leader 

to demonstrate justice through actions. Justice is clear and easy to 

accomplish when the problem is black and white. Unfortunately, most 

real-world situations a leader faces are varying shades of gray. In such 

circumstances, competing views of justice vie for primacy in the leader’s 

mind. The ancient Jewish King Solomon’s famous judgment between two 

mothers claiming a single child as their own is a timeless example of the

real-world wisdom required of today’s leaders.43 The historical account

also demonstrates the reward of true justice, noting that, “When all Israel 

heard the verdict they held the king in awe because they saw that he had 
22

wisdom from God to administer justice.”44

How do we practically administer such justice? Former commander 

of AFMC Gen Gregory “Speedy” Martin provided a wise framework for 

such decisions during a personal interview. The general summed up his 

philosophy, stating, “You need to look at a problem from big to small 

while ensuring you get the black and white right.”

This is the power of justice in 

effecting positive cultural change—a 3,000 year old lesson relearned.

45

Jack was a hard-working employee and recognized expert in his 

field for almost 10 years. Jill was a highly-motivated, dedicated employee 

with just over a year’s experience. In a meeting, Jack’s frustration with 

Jill’s performance on an issue boiled over in a series of expletives—

unacceptable behavior in a professional organization. Jill was rightly 

offended by Jack’s action and demanded restitution. Since Jack was a 

subcontract employee, the commander’s decision was binary. Legal 

counsel informed him that he could either (1) fire Jack; or (2) do nothing. 

The contract afforded no other options. On a small scale he was justified

with either course of action, but from a big-picture perspective that 

considered organizational culture and justice neither were acceptable 

options. Doing nothing would send the workforce a message that Jack’s 

“Big to small”

requires deference to the long-term implications of a decision as opposed 

to short-term, local effects. “Black and white right” requires a leader to 

check the facts before rendering a decision. The following real-world

example is illustrative of the point.
23

expertise was valued over proper workplace relationships. What about 

firing? The facts from a commander-directed investigation by an 

individual outside the organization revealed similar incidents dating back 

across the 10 years of Jack’s employment. Taking time to understand the 

black and white revealed prior leadership’s implicit toleration of Jack’s

behavior as no disciplinary action or documentation existed for the 

previous events. To fire him over this latest incident would be 

hypocritical as leadership failed to maintain and enforce standards over 

the previous 10 years. Of the two sanctioned options, firing Jack was 

both the most expedient and the safest. Unfortunately, it was also 

unjust. In the end the commander, cognizant of the big picture, risked

his own position for justice by contacting the head of the subcontractor’s 

company directly. He worked an unsanctioned arrangement where Jack 

publicly apologized to Jill and also attended a week of sensitivity 

training—a punishment that fit the crime. In the end, workplace 

standards of conduct were clearly articulated and enforced and future 

commanders have documented evidence of the event. Most importantly,

Jill and the rest of the workplace perceived that justice was served.

Conclusion

As the Air Force matures as a service we must choose a culture for 

our continued long-term success. The zero-defect approach practiced by 

SAC during the service’s infancy offers short-term success, but the 

resulting culture of fear and reprisal is not conducive to sustained 
24

excellence. Conversely, the tolerant approach of QAF adopted during our 

adolescence provides short-term morale benefits, but its culture of

ambivalence lacks the discipline required to achieve “Excellence in All We 

Do.” Ultimately, long-term, high performance is possible by adopting a

fail-safe approach which paradoxically embraces failure through a 

mindful approach to building a resilient enterprise. This fail-safe culture 

occurs when leaders clearly articulate the boundaries of acceptable 

behavior and enforce them through just rewards and just discipline. It is

from inside the security of these clearly-defined boundaries that our failsafe culture will thrive.

Notes

 

1. Col David L. Goldfein, Sharing Success, Owning Failure (Maxwell 

AFB, AL: Air University Press, 2001).

2. Gen Ronald R. Folgleman, Air Force Standards of Accountability, 

10 August 1995 video, Air University, Maxwell AFB, AL.

3. Mark Thompson Washington, "So Who's To Blame?” Time, 3 July 

1995.

4. Folgleman, Air Force Standards of Accountability.

5. Mark Thompson Washington, "Way, Way Off in the Wild Blue 

Yonder,” Time, 29 May 1995.

6. James R. Schlesinger, Report of the Secretary of Defense Task Force 

on DoD Nuclear Weapons Management. Phase I: The Air Force Nuclear 

Mission, (Washington, DC: Secretary of Defense, 2008), 1.
25

 

7. Air Force Global Strike Command, 13 November 2010 welcome 

page, http://www.afgsc.af.mil/main/welcome.asp.

8. Air Force Nuclear Task Force, Reinvigorating the Air Force Nuclear 

Enterprise (Washington, DC: Headquarters US Air Force, 2008), 12.

9. US Air Force, “US Air Force Mission,” 

http://www.airforce.com/learn-about/our-mission/ (accessed 10 

December 2010).

10. Air Force Systems Command, "1989 AFSC Total Quality 

Managment Briefing,” http://www.school-forchampions.com/tqm/pdf/AFSC_TQM_Presentation.pdf (accessed 

December 7, 2010).

11. Graham W. Rinehart, "How the Air Force Embraced ‘Partial 

Quality’,” Air and Space Power Journal 20, no. 4 (Winter 2006), 34.

12. Gen John P. Jumper (graduation address, Senior NCO Academy, 

Maxwell AFB, AL, 27 July 2001).

13. Ibid.

14. Legacy in the officer performance reporting (OPR) system manifests 

itself through a culture of inflated appraisals. Today, an average OPR 

reads with enough superlatives to justify the award of a medal for one’s 

actions throughout the year. In this environment, the distinction between 

an average OPR and outstanding OPR is recognizable only to a discerning 

eye. In effect, it is what is not said that is fundamentally more important 

than what is written on the OPR. Such a system perpetuates a degree of 
26

 

cultural dishonesty when it both insulates leaders from making hard 

decisions about the relative performance of their subordinates and also 

allows them to communicate unpleasant feedback indirectly.

15. Air Force Materiel Command Instruction 90-104, Implementing 

AFSO21 Initiatives, 29 September 2008, para 1.1.

16. Ibid., para 1.2.1.

17. Ibid., para 1.2.2.

18. Officer X, interview by the author, 17 November 2010.

19. Ibid.

20. Department of Defense, Narrative Summaries of Accidents Involving 

U.S. Nuclear Weapons: 1950–1980, April 1981, i–32.

21. Ibid., i–32.

22. Ibid., 8.

23. Jim Collins, Good to Great (New York: HarperCollins Publishers, 

Inc., 2001), 52.

24. Ibid., 133.

25. William J. Perry, interview by Linda D. Kozaryn, American Forces 

Press Service, 6 August 1996.

26. Kathleen M. Sutcliffe and Karl E. Weick, Managing the Unexpected

(San Francisco: Jossey-Bass, 2007), 9.

27. “Flight Safety Statistics,” US Air Force Safety Center, 2010, 

http://www.afsc.af.mil/shared/media/document/AFD-080407-052.pdf.

The 24 September 2008 publication of AFI 91-202, US Air Force Mishap 
27

 

Prevention Program, defines a Class A mishap as a mishap resulting in 

one or more of the following: (1)Direct mishap cost totaling $1,000,000 or 

more; (2) A fatality or permanent total disability; or (3) Destruction of a 

DOD aircraft. Note: A destroyed remotely piloted aircraft 

(RPA)/unmanned aircraft system is not a Class A mishap unless the 

criteria in paragraphs 1.10.1.1. or 1.10.1.2. are met.

28. Ibid. RQ-1, RQ-4, and MQ-9 combined lifetime rate versus U-2, E3, E-4 and E-8 combined lifetime rate. Initially, the higher RPA rates 

were of minimal concern to the Air Force which viewed them as a 

“replaceable” asset. Increasingly, however, the Air Force is more 

concerned with the high RPA mishap rates due to their increasing 

monetary cost and mission capability impacts. Some of the higher rate 

may be attributable to the newness of these systems; however, the root 

cause of the majority of these accidents is traceable to RPA design and 

testing standards lacking the redundancy and rigor of manned aircraft.

29. Sutcliffe and Weick, Managing the Unexpected, 52.

30. Ibid.

31. Although the Air Force does not publish official statistics on 

leaders fired for cause, open press reports of discrete events indicate 

commanders involved in the nuclear enterprise are relieved from 

command at a per command billet rate at least an order of magnitude 

greater than the rest of the Air Force. Due to the lack of data, it is 
28

 

impossible to objectively quantify the validity of this claim, but in the 

most basic sense its objective reality is irrelevant.

32. Donald M. Taylor, Stephen C. Wright, and Karen M. Ruggiero, 

"The Personal/Group Discrimination Discrepancy: Responses to 

Experimentally Induced Personal and Group Discrimination,” Journal of 

Psychology 131, no. 6 (2001): 847–58; Dr. Jack J. Kasulis and Dr. Robert 

F. Lusch, "Validating the Retail Store Image Concept," Journal of the 

Academy of Marketing Science 9, no. 4 (1981): 419–35; and Maria 

Sillanpää, "The Body Shop Values Report—Towards Integrated 

Stakeholder Auditing," Journal of Business Ethics 17, no. 13 (1998): 

1,443–56.

33. Kasulis and Lusch, "Validating the Retail Store Image Concept,”

420.

34. Sillanpää, "The Body Shop Values Report,” 1,451.

35. Collins, Good to Great, 52.

36. Sutcliffe and Weick, Managing the Unexpected, 131.

37. Ibid., 135.

38. Goldfein, Sharing Success, Owning Failure, 74.

39. Gary Ezzo and Anne Marie Ezzo are authors of 22 books on 

parenting which have been translated into 19 languages with over 8 

million copies sold.

40. Gary Ezzo and Anne Marie Ezzo, Growing Kids God's Way

(Louisiana, MO: Growing Families International, 2008), 146.
29

 

41. Michael Hoffman and Kent Miller, "Minot Airmen Fell Asleep 

with Classified Nuke Hardware,” Military Times, 24 July 2008, 

http://www.militarytimes.com/news/2008/07/airforce_nuclear_072408

w/ (accessed 20 December 2010).

42. Perry M. Smith, Rules and Tools for Leaders (New York: Avery 

Publishing Group, 1998), 27.

43. 1 Kings 3:16–28 (New International Version).

44. Ibid., 3:28.

45. Gen Gregory S. Martin, interview with the author, 8 December 

2010.