On April 14, 1994, 7.36am AWACS radar airplane takes off. This place is on surveillance (observation) mission, watching over Iraqi airspace. At the same day, a United Nations humanitarian operation takes place. This aims to help Kurds who fled to refugee camps in the mountains in the north of Iraq during the First Gulf War. 8.45am AWACS are in the position to “provide comfort”.
F-15 Eagle Fighters
- Fighters always fly in pairs — the lead and the wingman. An absolute rule states that wingman is always under the lead’s orders, even if the wingman is more experienced (e.g. 1100 hours of flight compared to 656 and 15 combat missions compared to 11).
- Planes Fly at High Attitudes
- Since the establishment of No Fly Zone — there was only one violation (one plane shot down)
- Pilots receive a flow sheet indicating all scheduled flights in the No Fly Zone. Black Hawks were not mentioned on that sheet.
- Officer who briefed F-15 pilots about the context of their mission was aware of Black Hawks mission but failed to mention it.
- At the take off, fighters asked about any potential new information. The answer was negative.
- After detecting radar signal and Friend or Foe identification failure, the lead’s first assumption was that the signal might be coming from the ground vehicles.
- Visual identification failed. To confirm identification and communication, the lead checked appearance of the helicopters in this enemy aircraft guidebook. He was unsure about the vehicles name.
- In reality, Black Hawks are dark green with forest-type camouflage while the Iraqi Hinds are beige with desert type camouflage.
- A helicopter does not normally pose a serious threat to a fighter plane (which is armed and generally much quicker)
E-3B AWACS Radar Aircraft
- The plane is piloted by four men. Surveillance and communication system is operated by a large crew of 14 people. Three teams include a (1) Maintenance Team, (2) Surveillance Section (detection and monitoring potential targets) and (3) Weapon Section (conducting combats and guidance of aircrafts and arm set up). On this particular mission, AWACS is also carrying (1) a representative command unit that directly responds to Mission Director (experiences fighter pilots), (2) a Turkish air traffic controller and (3) six instructors who assist the crew that is carrying their first mission together.
- F-15 fighters and helicopters are monitored by Weapon Section but by two different controllers. F-15 are monitored by a No Fly Zone controller and Black Hawks are assisted by Approach controller. Approach controller did not manage transfer information to the No Fly Zone controller because helicopters are rarely ventured deep into No Fly Zone.
- AWACS and their crew is in high demand. They face fatigue of crews and equipment. This particular crew received only one simulation training session. Additionally, many important members such as Commanding Officer and Mission Crew Commander are missing.
- Black Hawks were not mentioned during mission pre-flight briefing. There is no specific procedure regarding the coverage of helicopter flights by AWACS.
- Six instructors were present. During the sequence of events that led to the destruction of Black Hawks, some instructors were taking a break, others — sleeping, reading or resting.
- Helicopters fly at low attitudes and in between the mountains. They are hard to monitor and can quickly lose radar signal.
- The fighter pilot did not have enough experts in areal control and radars.
UH-60 Black Hawks
- Black Hawks were on United Nations humanitarian mission. They were transporting UN officials to meet Kurdish leaders. This type of mission is common but the duration and location of the meeting is unpredictable. As a result, the mission was not planned in detail.
- AWACS crew does not consider the helicopters to be one of the objects to monitor or control. These were the combat, transport, supply, intelligence and interference aircrafts, not humanitarian mission monitors. This time, they were doing it “as a favour”.
- Helicopter pilots were not consisted in their cooperation with AWACS. Sometimes they refrained from signalling or reporting on the progress of their mission.
- Air Force changed electronic codes of the identification system Friend or Foe. They added a specific code for No Fly Zone. Helicopter unit was not informed by this and thus their system was out of date.
- Helicopter units were not aware they were affected by an order “no aircraft enter the No Fly Zone before it’s swept”. According to them, this is indented to other airplanes. Black Hawk pilots were not informed F-15 fighters are going into action.
- Black Hawks’ radio equipment is not compatible with F-15. Helicopters are also in the habit of maintaining the radio frequency required for flights over Turkey.
- The general commanding the Operation Provide Comfort (AWACS) regularly carries out missions as an F-16 pilot. In the F-16 fleet, pre-flight briefing always list the helicopter missions.
Failures at Three Levels
8.22am two UH-60 Black Hawks transport helicopters of US army fly off within No Fly Zone. 9.35am — they report their entry into the zone to the AWACS and land. 9.54am Black Hawks take off carrying 16 members of UN humanitarian operations team. They report departure and destination to AWACS and at 10.12am disappear from AWACS track.
9.35am fighters from US Air Force takes off. Their mission is to sweep the No Fly Zone. Fighters must ensure this zone is free of all aerial danger before coalition aircraft enter the space on their mission. They enter the zone at 10.20am and report themselves to AWACS. At 10.22am two F-15 fighters report a radar contact of an aircraft flying at low attitude and speed. AWACS respond it has no radar contact on this plane.
Using electronic system, the two fighter aircrafts interrogate if the detected plane is a Friend of a Foe. Response is negative. F-15 prepare for an interception. During visual identification, this looks like a soviet-made attack helicopter in service of Iraqi army. AWACS acknowledges this. A wingman fires a missile on the helicopter. Two Black Hawks are instantly destroyed and 26 people killed. This was done in eight minutes after the first radar contact. The wingman shot from an eight kilometres distance.
In a nutshell, F-15 pilots misidentified Black Hawks and AWACS crew failed to intervene. Helicopters were not integrated into task force and the identification system of Friend of Foe failed. The situation failed in three levels of failure.
Individual Level Failure (F-15 Fighters) – Cognitive Limitations
1. Ambiguous Stimulus
F-15 fighters were affected by sped and attitude towards Black Hawks helicopters. There was almost no information disconfirming that these were not Iraqi planes. Asking AWACS for confirmation, the fighters did search for differential cues, but received confirming signals.
2. Strong Expectations (Ambiguity)
Because of the rule “no aircraft in the zone before it’s swept”, fighter planes expect to see only enemies in the No Fly Zone. They should be the first to enter.
3. Cognitive Biases
Fighter pilots “wanted” to see the enemies. They are trained to fight agains enemies. Additionally, pilots are respected and perceived as “experts” (cognitive biases) when they do shoot down the bad guys.
4. Other Factors
There are harmful social interactions between the two pilots. Junior staff is pressured to act quickly and obey authority.
No one was accountable for reporting Black Haws to the F-15 fighters.
Group Level Failure (AWACS) – diffused responsibility
1. Weak Team
This was not a real team. The group members did not know each other well because they never done this job before. Individuals did not know how to work together. Additionally, they were supervised that added pressure to the team. Furthermore, the group did not have a clear leader thus — poor commanding culture.
2. Diffused Accountability
Everyone was responsible but no one was. This is called the fallacy of social redundancy.
Organisational Level Failure (Black Hawks) – System Complexity and Fight Coupling
1. Differentiation v.s. Integration Dilemma
US army lacks integration. It results in weak teamwork and coordination.
2. Size and Complexity
The organisation is made of multiple entities. Interaction is unexpected and difficult to perceive. Complex systems need to fight coupling. This is especially true when processes are time dependent, sequences of activities are fairly rigid, there is one dominant path to achieve goal and there is very little slack.
3. Practical Drift
Practical drift is defined as a slow and steady uncoupling of local practice from written procedures. It results in general loosening of globally defined rationality in favour of local adoption. This is then local perspective makes more sense and the global perspective. No one appears to be following global rules. We cannot fully comprehend the richness of complex situations by limiting ourselves to one or a series of isolated accounts. We must search for mechanisms that operate across individuals, groups and organisations.
Bazerman, M.H. and Moore, D.A., 1994. Judgment in managerial decision making (p. 226). New York: Wiley.