Rethinking the Commander Directed Downgrade (Q3/1) in a Just Culture World

Recently, I heard of a Commander Directed Downgrade in which a crew member missed a single checklist item. The missed item did not result in injuries or aircraft damage, but it did represent complacency and a breach of flight discipline. Although the Q3/1 did not result in any retraining action, the commander’s action reinforced that we are accountable when operating a multi-million dollar weapon system in which our actions or inactions could jeopardize the safety of fellow crew members. As a former squadron commander, I had also issued Commander Directed Downgrades, so I understood the commander’s intent and decision.

As a safety analyst, I wondered how often that particular checklist item had been missed in our C-130 and KC-135 fleets. If that checklist step is critical, why do we have only one crew member check it? It was a universal technique for other crew members to back each other up and verify that the checklist item was properly completed, so why not make it procedure?

The proactive Aviation Safety Action Program (ASAP)’s Just Culture enables us to look at crew member errors in a new light, allowing crew members to voluntarily report honest mistakes without fear of retribution. At first, the Just Culture concept clashed with my need for military accountability. Proactive safety provides insights into the strengths and weaknesses of our flight operations, but are we allowing people to walk away from accountability to gain access to the data? It became an ethical dilemma for me.

ACCOUNTABILITY

Holding your Airmen accountable for the safe operation of aircraft in executing a mission is a primary responsibility of a flying squadron commander. When Airmen fail to meet specific standards, disciplinary action is a necessary part of a commander’s responsibility to remind Airmen that we risk lives and equipment when we fail to properly operate a weapon system. Accountability is essential in military flying.

One way commanders emphasize accountability is through the Commander Directed Downgrade. Air Force Manual Instruction 11-202 V2 states that a squadron commander may direct a Commander Directed Downgrade on an aircrew member without administering an evaluation for flight discipline and flight safety breaches. Those breaches of flight discipline and flight safety were further defined by commanders, such as pilots exceeding aircraft limits (overspeed, over G), missed critical checklist items, and Air Traffic Control (ATC) deviations Although these deviations might have been honest mistakes, the Commander Directed Downgrade reinforces our culture of disciplined flying.

Although the Commander Directed Downgrade instilled accountability, the practice also created a counter-culture in which pilots were not allowed to make honest mistakes or did not voluntarily report mistakes. My first personal introduction to that counter-culture was in pilot training as I flew my T-37 500 feet past my assigned ATC altitude. My instructor pilot (IP) quickly turned off the Mode C of the transponder, then took the jet from me. Shortly thereafter, ATC called, stating, “It appears we lost your altitude readout.†After we were level at our assigned altitude, my IP responded, “We will recycle our transponder.â€

Although not reported, there were indeed times when we made “monumental†honest mistakes leading us to kiss the ground when we landed and proclaimed, “Boy, I will never do that again!†After those memorable flights, we did not walk into the Director of Operations’ (DO’s) office and say, “Let me tell you about my near-death experience!†Those self-critiquing moments became valuable lessons, which made us better aviators; however, we were unwilling to share those stories with our squadron leadership for fear of retribution.

Although there was accountability with Commander Directed Downgrades, there were more mistakes than reported, creating weaknesses in our procedures and training that were never exposed or corrected until a Class A mishap occurred. Unfortunately, we saw those weaknesses at the cost of lives and aircraft.

As we learn from safety investigations, Class A mishaps are often a series of honest mistakes or failures that were not resolved prior to impact. The subsequent safety investigation may not show how often those errors or mishap factors occur in everyday flying.

PROACTIVE SAFETY AND JUST CULTURE

In the 1990s, the U.S. civilian airline industry underwent a transformational safety change of analyzing safety data before a mishap occurred. This change included Flight Operations Quality Assurance (FOQA) analysis, where Digital Flight Data Recorder data is analyzed regularly; using the Line Operations Safety Audit (LOSA) and Threat and Error Management to look for pilot error on daily flights; and ASAP, a pilot self-reporting system in which they shared their mistakes. These safety programs needed voluntary pilot involvement to get maximum participation.

The Just Culture Concept acknowledges that pilots make honest mistakes in performing their duties. Professional aviators are human and likely to commit errors, so organizations need to identify and analyze these errors before mishaps occur. Thus, the airlines used the concept to allow pilots to acknowledge and report honest mistakes without fear of disciplinary action that would jeopardize their professional license.

Just Culture slowly took root in the U.S. civilian airline industry. Although the Just Culture concept is codified in legal terms and processes, the core concept remains intact—it is better to acknowledge and report mistakes than to hide them. As a result, the civilian airline industry has a robust safety database in which errors are identified, analyzed, and rectified. Proactive safety programs have dramatically improved the airline safety record.

CLASH OF CULTURE—ACCOUNTABILITY VS. JUST CULTURE

The Air Force has embraced the Just Culture, as it is beneficial to acknowledge aircrew errors; however, there are concerns that Just Culture lacks accountability or is a “get out of jail free card.†Our military culture demands that a commander take corrective actions, equating to a Commander Direct Downgrade.

I believe Just Culture does instill accountability and is not a “get out of jail free card.†Merriam-Webster defines accountability as “an obligation or willingness to accept responsibility or to account for one’s actions.†Although commanders want to verbally hear the Airman acknowledge responsibility, when a crew member files an ASAP, they acknowledge that “This is what I did wrong and what I learned.†I believe the written ASAP is accountability for honest mistakes.

If Just Culture had existed when I was a squadron commander, I would have championed it and ASAP rather than Commander Directed Downgrades as accountability for honest mistakes. In two cases, however, I still would have opted for the Commander Directed Downgrades because the aircrew members willfully disregarded procedures, deliberately chose and executed a risky course of action, and did not communicate their intentions to the crew. These two cases were not honest mistakes; thus, I would not change my decision on disciplinary action. The Commander Directed Downgrade is still a viable tool for commanders when crew members willfully disregard standards and operate an aircraft unprofessionally, but not for honest and unintentional deviation from standards.

The Just Culture concept is a valuable tool to report honest mistakes and uphold accountability.

As commanders, we sometimes need to remind ourselves that most of our aircrew members are true warriors. They are critical of their own mistakes, have a strong desire to improve their skills, are genuinely disappointed when they fail, and have already critiqued themselves.

Most importantly, a Just Culture enables proactive safety programs to provide insights into the flaws within our flying operation without learning those lessons through a Class A mishap. I would rather read an ASAP, LOSA Report, or review a military FOQA analysis than read a Class A mishap report. There is nothing worse than discovering that a mishap in which crew members lost their lives was preventable.