AIR UNIVERSITY

TOWARDS A FAIL-SAFE AIR FORCE CULTURE

Creating a Resilient Future While Avoiding Past Mistakes 

by

Todd C. Ericson, Lt Col, USAF

A Research Report Submitted to the Faculty

In Partial Fulfillment of the Graduation Requirements

16 February 2011

[Cleared for public release 7/25/2011 as amended; AETC-2011-0598]
i

DISCLAIMER

The views expressed in this academic research paper are those of the author and do not reflect 

the official policy or position of the US government or the Department of Defense. In accordance 

with Air Force Instruction 51-303, it is not copyrighted, but is the property of the United States 

government.
ii

Contents

DISCLAIMER................................................................................................................................. i

Contents.......................................................................................................................................... ii

Biography.......................................................................................................................................iii

Towards a Fail-Safe Culture ........................................................................................................... 1

Tolerance-Based Culture ................................................................................................................ 3

Zero-Defects Culture ...................................................................................................................... 5

Fail-Safe Culture............................................................................................................................. 7

Building a “Fail-Safe” Culture........................................................................................................ 9

Rewards and Punishment in a Fail-Safe Culture .......................................................................... 11

Justice in a Fail-Safe Culture ........................................................................................................ 14

Conclusion .................................................................................................................................... 16

Bibliography ................................................................................................................................. 18

Endnotes........................................................................................................................................ 20
iii

Biography

Lt Col Todd Ericson entered military service in 1987 as an Air Force Academy cadet. He 

graduated in 1991 with a Bachelor’s of Science degree in Aeronautical Engineering and holds a 

Master’s of Science in Aerospace Engineering from the University of Maryland, College Park. 

He is an experimental test & Command Pilot with more than 7,700 hours experience in 

over 75 types, serving as an Evaluator Pilot in the C-21A, F-16 and classified aircraft. His 

experience includes 230 hours of combat and more than 75 hours combat support time. 

Lt Col Ericson has served as Commander of the 416th FLTS and Chief of Safety. 

Significant awards include the Empire Test Pilots School McKenna and Hawker Hunter 

Trophies, the ATC Commander’s Trophy and 7 Air Medals. 

He is currently a student at the Air Force War College at Maxwell AFB, AL.
Page 1

Towards a Fail-Safe Culture

Commander of the 1st Fighter Wing, Colonel Steve Goldfein, 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

Air Force Chief of Staff General Ronald R. Fogleman 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” following 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 in 

either or both are exposed.

2 In the 

immediate aftermath of this incident only one officer, the Airborne Warning and Control System 

(AWACS) commander Captain Jim Wang, was court-maritaled for the death of 26 friendly 

personnel.3 Others involved, to include the F-15 pilots who actually shot down the helicopters, 

received non-judicial 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 after Colonel William E. Pellerin’s court martial in the notorious 

24 June 1994 crash of a B-52 at Fairchild AFB – 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 and the shipping of non-nuclear intercontinental ballistic missile components to Taiwan are 

analogous contemporary events. Dr. Schlesinger’s 2008 report to the Secretary of Defense 
Page 2

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 The Secretary of the Air 

Force Michael Wynne and Air Force Chief of Staff General T. Michael Moseley both resigned in 

the wake of these incidents, and on October 24th 2008 the new Secretary of the Air Force 

Michael Donley and Air Force Chief of Staff General 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 of complacency or shortcuts as we rebuild a 

“zero-defect” culture.” 8

Each of these incidents represents a catastrophic institutional failure – failures which

must be prevented. Ceding the impossibility of omnipresence, Col 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 Tolerance-Based 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, long-term 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 
Page 3

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 

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

QAF transformed Air Force Regulations into softer Instructions and replaced harsh 

Inspections with gentler Quality Air Force Assessments (QAFA). Graham Rinehart summarized 

The proposal was seductive as Demming’s Plan, Do, Check, Act (PDCA) cycle 

that transformed post-WWII Japanese industry paralleled Colonel 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. 
Page 4

the impact to the force as “Airmen 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 General John Jumper in a 2001 

speech to the Senior NCO 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 AF 

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 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 AFI was designed to ensure personnel understood 

implementation was not optional. By the mid 1990’s QAF had fallen out of vogue, never 

obtaining the sweeping cultural change envisioned. Its legacy, however, survives in both the 

Officer Performance Reporting (OPR) system

Justice had not been served. 

14

AFSO21 strives to eliminate many of QAF’s deficiencies while simultaneously 

reinforcing its strengths. According to Air Force Material Command Instruction (AFMCI) 90-

and under the auspices of the Air Force Smart 

Operations for the 21st Century (AFSO21) program. 
Page 5

104, “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.”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 towards 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 General Curtiss LeMay SAC embodied a 

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 out-brief. 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

approach pressured honorable men to sacrifice their integrity in support of a Zero-Defects 

façade. Compelling testament is that the Airman, today a Lt Col, 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. 
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Nuclear Weapons: 1950-1980” thirty-two 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%) 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, NM. The weapon’s high explosives detonated upon 

impact, leaving 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 

high-performing 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 Zero-Defects 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. 
Page 7

United States 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, highlyreliable operations are essential. Despite these consequences, Weick and 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 template already exists and 

even thrives inside well-established Air Force organizations today. 

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. 

Fail-Safe Culture

The concept of a Fail-Safe culture is straight forward. 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. 
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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% reliability is not possible in parts 

conceived, designed, built, maintained and operated by humans. Therefore, 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 accidents reports are fed back into the 

system. These data are incorporated as improvements in subsequent models, modifications to 

existing aircraft or as changes to operations and maintenance manuals. A parallel process focuses 
Page 9

on the operators and the two merge in our safety organizations. The Air Force Safety system, 

guided by the precept of privilege or non-attribution, effectively reduced non-combat 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 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 

Unmanned Aerial Vehicle (UAV) 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.

While 

impressive, the 62 years of data also demonstrate the Air Force’s inability to achieve a ZeroDefect flying program. 

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
Page 10

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 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 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
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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. Kasulis and Dr. Lush conclude from their study of business-customer relations 

that “In other words, perceptions are reality for the consumer regardless of objective reality.”33

Sillanpää concludes from her research on effective, long-term 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 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 
Page 12

correlation between those companies which significantly out-performed 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 towards 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.

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, Professor 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 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
Page 13

exhibit high standards of discipline but also are extremely rigorous in learning from small 

mistakes as a means to prevent future catastrophes. 

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 

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. Colonel William 

E. Pellerin was court martialed in the Fairchild B-52 crash because he, and others in leadership 

roles, failed to properly discipline Lt Col Holland. Although Lt Col 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.

Beyond failure avoidance, implementation of consistent and fair discipline inside of wellestablished boundaries also bears the positive by-product of instituting a sense of comfort and 
Page 14

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 Ezzo39, amplify Col 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 shootdown, 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 re-affirming the standards and levying a just punishment for their actions,

General Fogleman both re-calibrated 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. 

Major General Perry M. Smith dedicates an entire chapter of his book Rules and Tools for 

Is it

reasonable to expect others will self-report future problems?
Page 15

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.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 grey. 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 wisdom from God to administer justice.”44

How do we practically administer such justice? Former Commander of Air Force 

Material Command General 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 

“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.
Page 16

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 expertise was 

valued over proper workplace relationships. What about firing? The facts from a commanderdirected 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 longterm 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 

excellence. Conversely, the tolerant approach of QAF adopted during our adolescence provides 
Page 17

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 Fail-Safe culture will thrive. 
Page 18

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Management. Phase I: The Air Force Nuclear Mission, Washington, DC: Secretary of 

Defense, 2008.

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Page 19

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Military Times. July 24, 2008. 

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December 20, 2010).

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Unknown. Book of 1st Kings. Public Domain, 1015 B.C.

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December 10, 2010).

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

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1996.
Page 20

Endnotes

 

1 Colonel David L. Goldfein, Sharing Success, Owning Failure.

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

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

4 General Ronald R. Folgleman, Air Force Standards of Accountability.

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

6 James R. Schlesinger 2008, Report of the Secretary of Defense Task Force on DoD 

Nuclear Weapons Management. Phase I: The Air Force Nuclear Mission, 1.

7 Air Force Global Strike Command.

8 Air Force Nuclear Task Force, Reinvigorating the Air Force Nuclear Enterprise, 12.

9 US Air Force Mission.

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

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

12 General John P. Jumper, "Speech to SNCO Academy.”

13 Ibid.

14 Legacy in the 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 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 feeback indirectly. 

15 AFMC/A8T, AIR FORCE MATERIEL COMMAND INSTRUCTION 90-104, para 1.1.

16 Ibid., para 1.2.1.

17 Ibid., para 1.2.2.

18 Officer X, Interviewed by Lt Col Todd Ericson.

19 Ibid.

20 Department of Defense, Narrative Summaries of Accidents Involving U.S. Nuclear 

Weapons: 1950-1980, i-32.

21 Ibid., i-32.

22 Ibid., 8.
Page 21

 

23 Jim Collins, Good to Great, 52.

24 Ibid., 133.

25 William J. Perry interviewed by Linda D. Kozaryn.

26 Kathleen M. Sutcliffe and Karl E. Weick, Managing the Unexpected, 9.

27 US Air Force Safety Center, 2010. The 24 Sept 2008 publication of AFI 91-202 

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 

UAV/UAS 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, E-3, E-4 and E-8 

combined lifetime rate. Initially, the higher UAV rates were of minimal concern to the 

USAF which viewed them as a “replaceable” asset. Increasingly, however, the USAF 

is more concerned with the high UAV 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 UAV design and testing standards lacking the redundancy and rigor of 

manned aircraft. 

29 Kathleen M. Sutcliffe and Karl E. Weick, Managing the Unexpected, 52.

30 Ibid., 52

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 

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."; Jack J. Kasulis, PhD and Robert F. Lusch, PhD, "Validating 

the Retail Store Image Concept," Volume 9, Number 4; Maria Sillanpää, "The Body 

Shop Values Report - Towards Integrated Stakeholder Auditing," Voume 17, Number 

13.

33 Jack J. Kasulis, PhD and Robert F. Lusch, PhD, "Validating the Retail Store Image 

Concept," Volume 9, Number 4, 420.

34 Maria Sillanpää, "The Body Shop Values Report - Towards Integrated Stakeholder 

Auditing," 1998, Voume 17, Number 13, 1451.

35 Jim Collins, Good to Great, 52.

36 Kathleen M. Sutcliffe and Karl E. Weick, Managing the Unexpected, 131.

37 Ibid., 135.
Page 22

 

38 Colonel David L. Goldfein, Managing the Unexpected, 74.

39 Authors of 22 books on parenting translated into 19 languages with over 8 million 

copies sold.

40 Gary Ezzo and Anne Marie Ezzo, Growing Kids God's Way, 146.

41 Michael Hoffman and Kent Miller, "Minot airmen fell asleep with classified nuke 

hardware.”

42 Perry M. Smith, Rules and Tools for Leaders, 27.

43 Unknown, Book of 1st Kings, 1015 B.C., Ch 3, vs 16-28. Text of 1 Kings, Ch 3 vs 16-

28, New International Version: A Wise Ruling 16 Now two prostitutes came to the 

king and stood before him. 17 One of them said, “Pardon me, my lord. This woman 

and I live in the same house, and I had a baby while she was there with me. 18 The 

third day after my child was born, this woman also had a baby. We were alone; there 

was no one in the house but the two of us. 19 “During the night this woman’s son died 

because she lay on him. 20 So she got up in the middle of the night and took my son 

from my side while I your servant was asleep. She put him by her breast and put her 

dead son by my breast. 21 The next morning, I got up to nurse my son—and he was 

dead! But when I looked at him closely in the morning light, I saw that it wasn’t the 

son I had borne.” 22 The other woman said, “No! The living one is my son; the dead 

one is yours.” But the first one insisted, “No! The dead one is yours; the living one is 

mine.” And so they argued before the king. 23 The king said, “This one says, ‘My son 

is alive and your son is dead,’ while that one says, ‘No! Your son is dead and mine is 

alive.’” 24 Then the king said, “Bring me a sword.” So they brought a sword for the 

king. 25 He then gave an order: “Cut the living child in two and give half to one and 

half to the other.” 26 The woman whose son was alive was deeply moved out of love 

for her son and said to the king, “Please, my lord, give her the living baby! Don’t kill 

him!” But the other said, “Neither I nor you shall have him. Cut him in two!” 27 Then 

the king gave his ruling: “Give the living baby to the first woman. Do not kill him; she 

is his mother.” 

44 Ibid., Ch 3, vs 28.

45 General Gregory S. Martin, Personal interview with General Martin.