Customize Consent Preferences

We use cookies to help you navigate efficiently and perform certain functions. You will find detailed information about all cookies under each consent category below.

The cookies that are categorized as "Necessary" are stored on your browser as they are essential for enabling the basic functionalities of the site. ... 

Always Active

Necessary cookies are required to enable the basic features of this site, such as providing secure log-in or adjusting your consent preferences. These cookies do not store any personally identifiable data.

No cookies to display.

Functional cookies help perform certain functionalities like sharing the content of the website on social media platforms, collecting feedback, and other third-party features.

No cookies to display.

Analytical cookies are used to understand how visitors interact with the website. These cookies help provide information on metrics such as the number of visitors, bounce rate, traffic source, etc.

No cookies to display.

Performance cookies are used to understand and analyze the key performance indexes of the website which helps in delivering a better user experience for the visitors.

No cookies to display.

Advertisement cookies are used to provide visitors with customized advertisements based on the pages you visited previously and to analyze the effectiveness of the ad campaigns.

No cookies to display.

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.

Categories
Root Cause Analysis
-->
Show Comments

Leave a Reply

Your email address will not be published. Required fields are marked *