The ASAP Report That Wasn’t … But Should Have Been … the Sequel

A few years back, a published article entitled “The ASAP Report That Wasn’t … But Should Have Been!†was written by a program manager associated with the Air Combat Command. The article recounted a close brush between two Lakenheath F-15s and a number of skydivers, which occurred near the northern part of London, England. Luckily, for all involved, the skydivers and the aircraft narrowly avoided collision. Closure speeds were likely in excess of 400 miles per hour and video footage of the event, which was shot by one of the skydivers, showed that the closest approach was near enough to provide “clearly distinguishable†details of the F-15s. A subsequent investigation by the United Kingdom Airprox Board (UKAB) provided details of the event as well as recommendations on how to prevent additional recurrences.

Unfortunately, for those who do not peruse UKAB reports or steer aircraft in the United Kingdom, little to none of this investigative report was shared. Essentially, the F-15 aircrews played “we have a secret†even when they were made aware of the incident shortly after it occurred. Perhaps the aircrews did not intentionally withhold information, but rather they failed to use a tool specifically designed to disseminate this type of information to other F-15 aircrews, the Combat Air Forces (CAF), and the USAF as a whole. The information obtained and the lessons learned from the London incident, which were applicable to dozens of Mission Design Series (MDS) and thousands of aviators, were relegated to an obscure report within a foreign country and reached only a sliver of the aviation community.

As news of the close call slowly spread through the CAF by word of mouth, it eventually reached the ears of someone familiar with proactive safety and the Airman Safety Action Program (ASAP¹). They asked: “Did the aircrews fill out an ASAP report?†When it was ultimately determined that the aircrew had not, efforts were made to capture their perspectives before their first-hand knowledge of the event was lost over time. These efforts were successful, and the events of that day were captured in the winter 2020 edition of the Combat Edge magazine as summarized previously.

Unfortunately, the “we have a secret†game is not limited to only one MDS, organization, or geographic location. Events and subsequent lessons learned are regularly withheld from the wider aviation community and ultimately forgotten. Opportunities to prevent embarrassment, injuries, and loss of life, as well as to save aircraft and equipment, are lost to time when ASAP is not used.

A similar type of information retention occurred within the Air Force Global Strike Command (AFGSC), where details of an incident made the rounds through AFGSC back shops, bars, and mission planning rooms over the years. It has become a story to tell young crew chiefs or new copilots upon their arrival to emphasize the government purchasing process, to prepare for unforeseen consequences, and to be attentive at all times. Similar to the F-15/skydiver encounter, no one was hurt, no damage was done, and several lessons were learned. However, unlike the F-15/skydiver encounter, this information was neither documented nor captured in an ASAP report. It is the “ASAP Report That Wasn’t … But Should Have Been … The Sequel.â€

This story originated a few years back at Dyess Air Force Base (AFB), TX. They were experiencing a particularly cold snap of weather which, although unusual, is not uncommon or rare for central Texas. As part of normal procedures for those weather conditions, B-1s are subject to a preflight dousing of anti-ice to remove snow and ice from the fuselage, wings, and control surfaces. As the aircraft was being doused, the fluid would eventually fall or drain down to the concrete ramp and coat the surface under the bombers with a thin layer, where it would reside until it eventually dissipated or washed away. Although not particularly slick by itself, the anti-ice was still a liquid and exhibited the subsequent reductions in friction that are associated with fluids.

Also, around the same time, B-1 units at both Dyess AFB and Ellsworth AFB, SD, were replacing their decades-old wooden chocks with new and “improved†chocks made of plastic and rubber. The new chocks were designed to last longer and were lighter and easier to handle. Unfortunately, and unbeknownst to anyone, the new chocks, which were made of different materials than the wooden ones, reacted differently when placed on surfaces covered with a thin layer of deicing fluid.

At Dyess AFB, after a B-1 was deiced and taxied from its parking location, a second B-1, that had just completed its sortie, was marshaled in to park. After reaching its final parking location, the new chocks were installed and the aircrew shut down the engines. With the engines and power off, the ground crew began their post-flight maintenance actions and the aircrew began to gather their gear before leaving the aircraft for the maintenance debrief. At this point, the pilot, while gathering some items, glanced up and noticed that the buildings in the distance were slowly moving farther away in his side windscreen. Startled, he looked again and everything in view—buildings, trucks, and people—were more distant. After a few seconds of confusion, the pilot realized that rather than everything moving away, his aircraft was actually sliding backward! It quickly dawned on him that the brakes and/or chocks were not holding, and his aircraft was slowly sliding backward like a giant sled on a snowy hill. He quickly alerted the copilot, and working together, they began procedures to perform an emergency auxiliary power unit (APU) start in the hope of getting power back on the aircraft and the brakes applied before sliding into an APU cart, bread truck, or worse.

At the same time, the ground crew also noticed the aircraft was moving, and they were scrambling to stop it. The pilot and copilot completed an emergency APU start and got power on the aircraft, which allowed them to apply brakes and stop the slide. The ground crew quickly reapplied the chocks, and after a few more checks to ensure the aircraft was finally parked, the aircrew shut down the APU and exited the aircraft. A quick check by the aircrew and maintenance showed that the chocks had been correctly installed, but the thin layer of anti-icing fluid on the ramp had been just enough to prevent the chocks from getting the necessary friction to hold the aircraft in place.

Shortly thereafter, the Wing Safety Office was informed of the incident. A brief investigation revealed that the new “improved†chocks had a lower coefficient of friction that prevented them from adhering as effectively as the old wooden chocks. After some debate, the determination was made that use of the new chocks would be discontinued, and the wooden chocks would once again be used until another replacement was found and fielded, which it was.

The incident at Dyess AFB is just one example of many, and it serves as a reminder that the ASAP program is a tool that anyone can use to mitigate danger—but it only works if it is used.

Overall, the entire incident was considered a “win.†The aircrew exercised proper emergency procedures, no one was hurt, and nothing was broken or damaged.

Nonetheless, guess who else was using those exact same “improved†chocks? Guess who else operated in a winter climate? Guess who else was deicing their aircraft? Guess who else had no idea that those exact same chocks had varying properties? It was the 28th Bomb Wing at Ellsworth AFB. The good news is that after several weeks, information about the new chocks made it to Ellsworth, and the AFB discontinued their use until newer, more effective chocks were acquired.

However, from another perspective, several weeks went by during which a known and potentially catastrophic hazard was unaddressed at a locale where the hazard had a higher probability of occurring. Imagine the fallout if an aircraft were damaged or someone was hurt at Ellsworth AFB, and if, during the subsequent Safety Investigation Board (SIB), it was discovered that a sister B-1 Wing was aware of the hazard, but the information had not been shared.

The ASAP program contained the policy, method, and process to share this information and address the problem. A simple ASAP submission by any of the air or ground crew members would have energized a system that could share the information throughout the B-1, Bomber, and/or CAF to inform others of the new chocks’ interaction with anti-icing fluid. Perhaps a lack of awareness or possibly hesitation was the reason that this safety program was not used. A golden opportunity to address a significant threat quickly and effectively was lost. Again, it was another ASAP report that wasn’t … but should have been.

To clarify, there was no intentional malice. The aircrews did what they thought was right, which was to inform the Wing Safety Office, and the Wing Safety Office personnel did what they thought was right, which was to start the bureaucratic process to remove the chocks from inventory. Notably, a few years ago, neither the proactive safety techniques nor the ASAP program concepts were well-known within the B-1 community.

Aviation, by definition, is inherently dangerous, and threats permeate every aspect of it; any minor issue could theoretically exacerbate the already risky business of flying. Minor omissions, human errors, or equipment failures could, and have, ultimately resulted in aircraft and equipment losses and damages, as well as human injuries and deaths. The incident at Dyess AFB is just one example of many, and it serves as a reminder that the ASAP program is a tool that anyone can use to mitigate danger—but it only works if it is used. The chocks incident should also be a reminder to think about the potential impact on aircraft safety as a whole rather than thinking myopically by limiting information to one unit or one locale. Use the ASAP program for what it was designed to do: share information, identify trends, and engage others. Turn ASAP reports that were not into ASAP reports that were.

¹ ASAP is intended to enhance and supplement safety programs and hazard reporting; it is not a substitute for appropriate leadership involvement. ASAP is an identity-protected, self-reporting system designed to encourage voluntary reporting of issues that increase risk to operations. ASAP augments existing safety reporting programs by capturing self-reported issues and events not normally disclosed by traditional hazard reporting and mishap prevention programs. ASAP involves leaders and Airmen in the mishap reduction process by capturing self-reported issues and events, analyzing resulting information for trends, educating personnel, and developing and implementing risk reduction or mitigation strategies.