October 22, 2007 | Mark Paradies

Monday Accident & Lessons Learned: Air Force Nuclear Weapon “Incident” Shows that SPAC Not Used Can Happen Anywhere When Enforcement is Weak

On August 29-30, a real nuclear weapon was shipped across the country in a B-52. This wouldn’t be news except for one problem … It was supposed to be just a missile with no nuclear weapon attached.

The Associated Press article said that the mistake occurred when people handling the weapon decided not to use a “complex schedule” under which they track the disarming, loading, and moving of weapons. Instead, the airmen had invented their own “informal” system.

Air Force Secretary Michael Wynne said:

“This was an unacceptable mistake and a clear deviation from our exacting standards. We hold ourselves accountable to the American people and want to ensure proper corrective action has been taken.”

The Air Force conducted a six-week investigation into the cause of the accidental shipment. The main corrective action reported by the Associated Press story was the punishment of 70 Air Force personnel.

The story says that the highest-ranking personnel punished are four officers relieved of their commands. This includes the 5th Bomb Wing commander at Minot, Col. Bruce Emig, who has been the base commander since June.

65 airmen have been decertified from handling nuclear weapons. The certification process looks at a person’s psychological profile, any medications they are taking, and other factors in determining a person’s reliability to handle weapons.

What lesson can everyone learn from this procedural failure? You don’t get strict compliance with lax enforcement. I’m not sure that the Air Force’s corrective actions are adequate, but this certainly sounds like a Management System – Standards, Policies, and Administrative Controls (SPAC) Not Used – Enforcement Needs Improvement root cause.

If you have high-risk systems, enforcement of procedure use has to be a high management and supervisory priority, or standards will slip.

Root Cause Analysis
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