What do you think?
Rate this book
Friendly Fire: The Accidental Shootdown of U.S. Black Hawks over Northern Iraq
On April 14, 1994, two U.S. Air Force F-15 fighters accidentally shot down two U.S. Army Black Hawk Helicopters over Northern Iraq, killing all twenty-six peacekeepers onboard. In response to this disaster the complete array of military and civilian investigative and judicial procedures ran their course. After almost two years of investigation with virtually unlimited resources, no culprit emerged, no bad guy showed himself, no smoking gun was found. This book attempts to make sense of this tragedy--a tragedy that on its surface makes no sense at all.
With almost twenty years in uniform and a Ph.D. in organizational behavior, Lieutenant Colonel Snook writes from a unique perspective. A victim of friendly fire himself, he develops individual, group, organizational, and cross-level accounts of the accident and applies a rigorous analysis based on behavioral science theory to account for critical links in the causal chain of events. By explaining separate pieces of the puzzle, and analyzing each at a different level, the author removes much of the mystery surrounding the shootdown. Based on a grounded theory analysis, Snook offers a dynamic, cross-level mechanism he calls "practical drift"--the slow, steady uncoupling of practice from written procedure--to complete his explanation.
His conclusion is disturbing. This accident happened because, or perhaps in spite of everyone behaving just the way we would expect them to behave, just the way theory would predict. The shootdown was a normal accident in a highly reliable organization.
With almost twenty years in uniform and a Ph.D. in organizational behavior, Lieutenant Colonel Snook writes from a unique perspective. A victim of friendly fire himself, he develops individual, group, organizational, and cross-level accounts of the accident and applies a rigorous analysis based on behavioral science theory to account for critical links in the causal chain of events. By explaining separate pieces of the puzzle, and analyzing each at a different level, the author removes much of the mystery surrounding the shootdown. Based on a grounded theory analysis, Snook offers a dynamic, cross-level mechanism he calls "practical drift"--the slow, steady uncoupling of practice from written procedure--to complete his explanation.
His conclusion is disturbing. This accident happened because, or perhaps in spite of everyone behaving just the way we would expect them to behave, just the way theory would predict. The shootdown was a normal accident in a highly reliable organization.
280 pages, Paperback
First published March 20, 2000
19 people are currently reading
158 people want to read
Ratings & Reviews
Friends & Following
Create a free account to discover what your friends think of this book!
Community Reviews
Displaying 1 - 13 of 13 reviews
March 8, 2019
As I did when I reviewed Joan Piper’s book, A Chain of Events, I need to begin with a set of disclaimers.
• I am a retired Air Force officer.
• I was a Mission Crew Commander (MCC) on the E-3 Airborne Warning and Control System (AWACS) aircraft.
• On the date of the shoot-down of the two Blackhawk helicopters over northern Iraq—April 14, 1994—I was deployed to Riyadh, Saudi Arabia, to fly missions enforcing the southern no-fly zone over Iraq for Operation Southern Watch/Desert Calm, the counterpart to Operation Provide Comfort (OPC).
• In July 1994, when the first investigation report was released, I was deployed to Incirlik Air Base, Turkey, to fly OPC missions. I was in the audience at the base theater when the report was briefed to the aircrews there the evening before it was released to the public.
• I knew slightly both of the MCCs who were on the AWACS crew the day of the shoot-down, and have since gotten to know one of the senior officers involved in the decisions on who to prosecute or not. I did not know the one AWACS officer who was ultimately court-martialed but declared not guilty by the jury.
Because this book was my second one on the shootdown, I was prepared for another difficult read. I also came to the book with a fair degree of skepticism. The author, Scott Snook, was an Army officer: what biases was he going to bring to the work? I had skimmed the book before I actually sat down with it and was concerned that, as a psychological study, it was going to be dry and uninformative.
I’m pleased to say that, on the first count, I think Snook did a fairly good job, although hardly a perfect one. More on that in a moment. On the second count, Snook’s in-depth and cross-level evaluation of the events, non-events, and individual, group, and organizational psychology of what happened was far better than I expected.
Snook introduces a number of concepts that are both challenging and revealing. The first is the idea of the “normal accident”—that in a complex system, which Operation Provide Comfort certainly was, with many moving parts that were not as tightly linked to each other as all of the players thought they were—some kind of accident of this magnitude is almost certain to happen if the operation goes on long enough. This might be, at first, a shocking and disturbing assertion, yet on deeper inspection, it reflects something that we understand intuitively: the more complex a device or situation is, the more likely it is that something will eventually fail.
The second concept Snook introduces is “practical action.” Practical, as used here, means “as in practice.” In other words, OPC began with an extensive set of rules and procedures, written down in dozens of different documents. Over time, however, the people having to implement those rules and procedures found them to be impractical, and so they created local rules and procedures that made sense—were “practical”—in their specific situation. Whether they made sense to the larger organization is another matter, one that the local practitioners did not have the perspective to be able to judge.
Over time, this movement to “practical action” led to Snook’s third concept, “practical drift,” in which more and more formal rules and procedures are replaced by locally-developed practical actions. Unfortunately, no one at any level, had the ability to see all of the changes that had occurred, until they culminated in two helicopters being shot down and 26 people dying: a “normal” accident.
Snook reveals how the actions at the individual level of the two F-15 pilots who fired the deadly missiles, the AWACS crew members who did nothing that could have stopped them, and the OPC leadership who was unaware of the brewing problems were practical and sensible to each at that moment. Unfortunately, they were also wrong.
But then Snook goes on to reveal how analyzing just the actions of these individuals or groups in isolation is not sufficient to understand how the shootdown occurred. It is also necessary to look at the interactions between the individuals, groups, and organizational levels, not just in those few tragic moments, but over the full three years of the life of OPC to that point, to gain a full understanding of what went wrong and why. In this way, this book is even more disturbing than Piper’s book. While Piper’s account of the struggles of the victims’ families to understand what had happened and why is deeply personal and emotional, Snook’s account is more chilling because of the inevitability of something happening during the course of the operation.
Perhaps Snook’s most disturbing conclusion, however, is that in complex organizations, when something goes badly wrong, it’s not possible to place blame in one location or on one individual because so many people and parts share in it: blame can’t be placed anywhere because it lies everywhere.
This is especially disturbing for the families of the victims. Piper’s book is, in many ways, a search for the one true villain, the one person on whom all blame could be laid. Ultimately, the Air Force, the Department of Defense, the General Accountability Office, and Congressional committees all failed to find that one person. The F-15 pilots were not criminally charged, and the one AWACS officer who was court-martialed was found not guilty.
As I read the book, I wondered if Mrs. Piper or any of the other family members had read it, and if it in any way would provide, if not solace, at least an explanation they could accept. Only one family member, the father of one of the Blackhawk pilots left reviews on Amazon and Goodreads, and he was worse than unsatisfied, going so far as to accuse Snook of lying. Sad as it is, this outcome is not surprising.
The book is not without its faults. It is rife with errors regarding Air Force operations, which Snook and his civilian editor at Princeton University Press likely did not even know were errors. To identify just two, a photograph identified as being of two F-15s actually shows two F-5s, and a later photograph shows the wrong model of F-15. Surely correct photographs were available. Second, Snook asserts that all of the AWACS crewmembers had the opportunity to intervene to stop the shootdown, even though two of the teams on the jet—the technicians and flight crew—had neither the situational awareness, the responsibility, the training, nor the equipment to do so.
Finally, I felt Snook went easy on the Army personnel at Eagle Flight, the operation flying the Blackhawk helicopters. To be fair, however, I must note that they were at several disadvantages: their base was far away from the one where the rest of the operation was headquartered, and the leadership of the flight was too junior (Captains or Majors) to have had the kind of influence necessary to have forced their operations to be properly integrated into the larger force. Those leaders evidently did not get the kind of support they needed from their superiors. Blaming this failure on interservice rivalry, however, is an easy way out, and I was disappointed to see Snook take it.
On balance, this book does a great service to the field of organizational psychology. Deep analyses of such tragedies are rare, in part because, as Snook himself notes, few have such a wealth of records and investigational material available to be analyzed. I can only hope that in the nearly 25 years since this tragic event, the Army, Air Force, and other military services, and other organizations, have learned the right lessons from this study: that “practical drift” from established procedures is inevitable, and that few operators and leaders will be aware of the drift under normal circumstances. Intense, multi-level vigilance is required if there is to be any hope of preventing, or at least reducing the magnitude of the “normal accidents” that are bound to occur. Highly recommended.
• I am a retired Air Force officer.
• I was a Mission Crew Commander (MCC) on the E-3 Airborne Warning and Control System (AWACS) aircraft.
• On the date of the shoot-down of the two Blackhawk helicopters over northern Iraq—April 14, 1994—I was deployed to Riyadh, Saudi Arabia, to fly missions enforcing the southern no-fly zone over Iraq for Operation Southern Watch/Desert Calm, the counterpart to Operation Provide Comfort (OPC).
• In July 1994, when the first investigation report was released, I was deployed to Incirlik Air Base, Turkey, to fly OPC missions. I was in the audience at the base theater when the report was briefed to the aircrews there the evening before it was released to the public.
• I knew slightly both of the MCCs who were on the AWACS crew the day of the shoot-down, and have since gotten to know one of the senior officers involved in the decisions on who to prosecute or not. I did not know the one AWACS officer who was ultimately court-martialed but declared not guilty by the jury.
Because this book was my second one on the shootdown, I was prepared for another difficult read. I also came to the book with a fair degree of skepticism. The author, Scott Snook, was an Army officer: what biases was he going to bring to the work? I had skimmed the book before I actually sat down with it and was concerned that, as a psychological study, it was going to be dry and uninformative.
I’m pleased to say that, on the first count, I think Snook did a fairly good job, although hardly a perfect one. More on that in a moment. On the second count, Snook’s in-depth and cross-level evaluation of the events, non-events, and individual, group, and organizational psychology of what happened was far better than I expected.
Snook introduces a number of concepts that are both challenging and revealing. The first is the idea of the “normal accident”—that in a complex system, which Operation Provide Comfort certainly was, with many moving parts that were not as tightly linked to each other as all of the players thought they were—some kind of accident of this magnitude is almost certain to happen if the operation goes on long enough. This might be, at first, a shocking and disturbing assertion, yet on deeper inspection, it reflects something that we understand intuitively: the more complex a device or situation is, the more likely it is that something will eventually fail.
The second concept Snook introduces is “practical action.” Practical, as used here, means “as in practice.” In other words, OPC began with an extensive set of rules and procedures, written down in dozens of different documents. Over time, however, the people having to implement those rules and procedures found them to be impractical, and so they created local rules and procedures that made sense—were “practical”—in their specific situation. Whether they made sense to the larger organization is another matter, one that the local practitioners did not have the perspective to be able to judge.
Over time, this movement to “practical action” led to Snook’s third concept, “practical drift,” in which more and more formal rules and procedures are replaced by locally-developed practical actions. Unfortunately, no one at any level, had the ability to see all of the changes that had occurred, until they culminated in two helicopters being shot down and 26 people dying: a “normal” accident.
Snook reveals how the actions at the individual level of the two F-15 pilots who fired the deadly missiles, the AWACS crew members who did nothing that could have stopped them, and the OPC leadership who was unaware of the brewing problems were practical and sensible to each at that moment. Unfortunately, they were also wrong.
But then Snook goes on to reveal how analyzing just the actions of these individuals or groups in isolation is not sufficient to understand how the shootdown occurred. It is also necessary to look at the interactions between the individuals, groups, and organizational levels, not just in those few tragic moments, but over the full three years of the life of OPC to that point, to gain a full understanding of what went wrong and why. In this way, this book is even more disturbing than Piper’s book. While Piper’s account of the struggles of the victims’ families to understand what had happened and why is deeply personal and emotional, Snook’s account is more chilling because of the inevitability of something happening during the course of the operation.
Perhaps Snook’s most disturbing conclusion, however, is that in complex organizations, when something goes badly wrong, it’s not possible to place blame in one location or on one individual because so many people and parts share in it: blame can’t be placed anywhere because it lies everywhere.
This is especially disturbing for the families of the victims. Piper’s book is, in many ways, a search for the one true villain, the one person on whom all blame could be laid. Ultimately, the Air Force, the Department of Defense, the General Accountability Office, and Congressional committees all failed to find that one person. The F-15 pilots were not criminally charged, and the one AWACS officer who was court-martialed was found not guilty.
As I read the book, I wondered if Mrs. Piper or any of the other family members had read it, and if it in any way would provide, if not solace, at least an explanation they could accept. Only one family member, the father of one of the Blackhawk pilots left reviews on Amazon and Goodreads, and he was worse than unsatisfied, going so far as to accuse Snook of lying. Sad as it is, this outcome is not surprising.
The book is not without its faults. It is rife with errors regarding Air Force operations, which Snook and his civilian editor at Princeton University Press likely did not even know were errors. To identify just two, a photograph identified as being of two F-15s actually shows two F-5s, and a later photograph shows the wrong model of F-15. Surely correct photographs were available. Second, Snook asserts that all of the AWACS crewmembers had the opportunity to intervene to stop the shootdown, even though two of the teams on the jet—the technicians and flight crew—had neither the situational awareness, the responsibility, the training, nor the equipment to do so.
Finally, I felt Snook went easy on the Army personnel at Eagle Flight, the operation flying the Blackhawk helicopters. To be fair, however, I must note that they were at several disadvantages: their base was far away from the one where the rest of the operation was headquartered, and the leadership of the flight was too junior (Captains or Majors) to have had the kind of influence necessary to have forced their operations to be properly integrated into the larger force. Those leaders evidently did not get the kind of support they needed from their superiors. Blaming this failure on interservice rivalry, however, is an easy way out, and I was disappointed to see Snook take it.
On balance, this book does a great service to the field of organizational psychology. Deep analyses of such tragedies are rare, in part because, as Snook himself notes, few have such a wealth of records and investigational material available to be analyzed. I can only hope that in the nearly 25 years since this tragic event, the Army, Air Force, and other military services, and other organizations, have learned the right lessons from this study: that “practical drift” from established procedures is inevitable, and that few operators and leaders will be aware of the drift under normal circumstances. Intense, multi-level vigilance is required if there is to be any hope of preventing, or at least reducing the magnitude of the “normal accidents” that are bound to occur. Highly recommended.
December 2, 2016
This is a dense and theoretically rigorous scholarly work. It capably illustrates important lessons in managing complex organizations and cultivates an honest empathy for every party in its readership.
That said, despite purporting to be comprehensive, the author handles some causal links far more rigorously than others:
1) General Pilkington's special approval of the VIP flight and the subsequent handling of that information is entirely omitted, despite providing some of the best evidence for inter-service communication failure and its underlying causes.
2) The Mode IV IFF issue almost completely ignored, including what we know if it's failure, why we don't know more (Army organizational considerations), and--most empathetically--the understandably profound effect its failure would've had on the other aircrews involved.
3) The author omits without discussion the one reason that's been advanced for the differing ATOs, namely that that Army form was never updated to provide a space for a second Mode I code, so the clerk who received the daily Air Force version simply ignored that number. Admittedly this is more obscure than the other two issues, so I'm unclear if this otherwise highly relevant topic was omitted for lack of knowledge, disbelief, or some other reason. ...I cannot help but notice, however, the published discussion concentrates heavily on Air Force organizational issues while the topics omitted are largely Army.
That said, despite purporting to be comprehensive, the author handles some causal links far more rigorously than others:
1) General Pilkington's special approval of the VIP flight and the subsequent handling of that information is entirely omitted, despite providing some of the best evidence for inter-service communication failure and its underlying causes.
2) The Mode IV IFF issue almost completely ignored, including what we know if it's failure, why we don't know more (Army organizational considerations), and--most empathetically--the understandably profound effect its failure would've had on the other aircrews involved.
3) The author omits without discussion the one reason that's been advanced for the differing ATOs, namely that that Army form was never updated to provide a space for a second Mode I code, so the clerk who received the daily Air Force version simply ignored that number. Admittedly this is more obscure than the other two issues, so I'm unclear if this otherwise highly relevant topic was omitted for lack of knowledge, disbelief, or some other reason. ...I cannot help but notice, however, the published discussion concentrates heavily on Air Force organizational issues while the topics omitted are largely Army.
March 1, 2015
Great read - a scholarly analysis of organizational behavior. Concept of practical drift as an extension of "normalization of deviation" on an organizational level. The 4 compartmental model makes great sense. Stages include design, drift, operations, failure occur in coupled systems. The easy solutions in this incident are discarded because they all make sense from the organizational perspective.
Highly recommended
Highly recommended
March 23, 2013
Used this book as a case study. A sad story that shows why everything we do counts.
August 3, 2019
Practical drift/sailing by example
This book was referred to me by a lecturer when I was struggling with making a rule based workplace. It took me over 4 years to read the whole book as I initially only read parts relevant to what I was doing at the time but reading the book has given me a lot of insight into managing safety inn a highly restrictive environment. A great read for all the tit-bits of info
This book was referred to me by a lecturer when I was struggling with making a rule based workplace. It took me over 4 years to read the whole book as I initially only read parts relevant to what I was doing at the time but reading the book has given me a lot of insight into managing safety inn a highly restrictive environment. A great read for all the tit-bits of info
August 6, 2018
Really enjoyed this book. As an air force member who flies in a crew-concept aircraft, I found there were lots of useful nuggets re individual, group, and organizational behaviour.
4/5, because there's a lot of academic verbiage that really doesn't need to be in the book.
4/5, because there's a lot of academic verbiage that really doesn't need to be in the book.
December 19, 2020
An incredibly interesting read. The analysis is so well done and is broken down in a way that made it easy to follow and understand the complex interactions. I was reading it for a class, but I think it would be a good book to read just for fun.
October 12, 2015
Not only did I read this book, I read the draft sent to me by Mr Snook before it was published, because my son Erik S. Mounsey was one of the pilots on board one of the two Black Hawk helicopters shot down that day on April 14.1994 over norther Iraq. The draft was sent to me by Mr Snook because Allen Hall whose son Michael Hall was also a pilot on the same Black Hawk as Erik.
Allen informed Mr Snook it would be better if he sent the draft to me rather than him, because I had become obsessed in my search for truth through fact finding in the 63 volumes of testimonial reports from the Department of Defense. The first item I observed in the draft was the date 1996 being presented at Princeton University for his Phd.
This finished draft was presented before the General Accounting Office (GAO) (Washington's watch dogs) who had been directed to look into the incident came out in November 5,1997 with its results. Several areas in the GAO investigation proved the Boards evidence in the shoot down to be erroneous, compared to Snook's draft. It also claimed the F-15 Fighter pilot Captain Eric Wickson who shot the trail helicopter who had been given Immunity to tell the truth could still be charged, based on evidence obtained from sources other than his testimony at the proceedings.
I called United States Army LTC Scott A Snook to give him an assessment of the critical areas missing in his draft, he was not prepared for my assessment, saying he does not lie, true, but he does not tell all the truth either. It disappoints me when a person of this caliber, West Point, ex military a victim of friendly himself, and University Professor felt it necessary use this Black Hawk shoot down as a platform to further his own ambitions with a book that is less than truthful, written in the halls of libraries while touring all over the country and Europe at the cost of further betraying the truth of the 26 lives 15 of whom were Americans.
There are times when well educated people such as the likes of Mr Snook will tout their pedigrees to overcome anything that threatens it. I for one would like to have an open dialogue to expose the truth of this shoot down, I was refused entry into the Pepperdine University speech he gave on the Black Hawk Shoot down.The truth will out, that unlawful command orders relayed to Lt. Colonel Randy May and Captain Wickson would cause the F-15 fighter pilots to engage two US Army UH 60 Black Hawks, evidence in the criminal investigation indicates this shoot down to be more of a design nature than alleged friendly fire.
Allen informed Mr Snook it would be better if he sent the draft to me rather than him, because I had become obsessed in my search for truth through fact finding in the 63 volumes of testimonial reports from the Department of Defense. The first item I observed in the draft was the date 1996 being presented at Princeton University for his Phd.
This finished draft was presented before the General Accounting Office (GAO) (Washington's watch dogs) who had been directed to look into the incident came out in November 5,1997 with its results. Several areas in the GAO investigation proved the Boards evidence in the shoot down to be erroneous, compared to Snook's draft. It also claimed the F-15 Fighter pilot Captain Eric Wickson who shot the trail helicopter who had been given Immunity to tell the truth could still be charged, based on evidence obtained from sources other than his testimony at the proceedings.
I called United States Army LTC Scott A Snook to give him an assessment of the critical areas missing in his draft, he was not prepared for my assessment, saying he does not lie, true, but he does not tell all the truth either. It disappoints me when a person of this caliber, West Point, ex military a victim of friendly himself, and University Professor felt it necessary use this Black Hawk shoot down as a platform to further his own ambitions with a book that is less than truthful, written in the halls of libraries while touring all over the country and Europe at the cost of further betraying the truth of the 26 lives 15 of whom were Americans.
There are times when well educated people such as the likes of Mr Snook will tout their pedigrees to overcome anything that threatens it. I for one would like to have an open dialogue to expose the truth of this shoot down, I was refused entry into the Pepperdine University speech he gave on the Black Hawk Shoot down.The truth will out, that unlawful command orders relayed to Lt. Colonel Randy May and Captain Wickson would cause the F-15 fighter pilots to engage two US Army UH 60 Black Hawks, evidence in the criminal investigation indicates this shoot down to be more of a design nature than alleged friendly fire.
September 24, 2012
How do the best trained pilots, operating under the control of the best airborne warning and control system, shoot down two US Army helicopters? Why were the helicopters there, counter to the air control order? Why wee the IFF codes incorrect? Why were different frequencies in use? Why didn't the control system say not to shoot? Why? Why?
Snook puts a good case for the overall environment that set the path to a tragedy... maybe not this specific one, but one was increasingly likely to occur.
Something to worry about in an organization where the organization is complex, very high risks, specialist involved, and (ironically) strong rule-based controls are put in place. Maybe one can say: not all of us are in such a situation... but then think of a hospital operating room where one might someday be. Or on an airplane (truly operating in such a situation).
His theory of 'practical drift' would be true in smaller, less catastrophic situations.
Snook puts a good case for the overall environment that set the path to a tragedy... maybe not this specific one, but one was increasingly likely to occur.
Something to worry about in an organization where the organization is complex, very high risks, specialist involved, and (ironically) strong rule-based controls are put in place. Maybe one can say: not all of us are in such a situation... but then think of a hospital operating room where one might someday be. Or on an airplane (truly operating in such a situation).
His theory of 'practical drift' would be true in smaller, less catastrophic situations.
July 26, 2015
I ran across this book in the references section of paper on Human Error and Complexity. Understanding shooting down of a couple US Blackhawks by US F-15s is the central purpose of this book. The author does a great job of explaining the human error factors in this event. He also creates a very interesting theory that has direct application in the understanding of human error in the industrial setting.
The theory is Practical Drift. The simple definition is "the slow steady uncoupling of practice from written procedure". This is a common occurrence in industrial settings. The author goes very deep into it's origins and implications. My experience indicates this is an important addition to the understanding of EHS pros. Practical Drift definitely applies to EHS processes.
The theory is Practical Drift. The simple definition is "the slow steady uncoupling of practice from written procedure". This is a common occurrence in industrial settings. The author goes very deep into it's origins and implications. My experience indicates this is an important addition to the understanding of EHS pros. Practical Drift definitely applies to EHS processes.
August 3, 2012
A must read, along with Sway, to understand the human factors that affect outcomes.
February 10, 2013
A really interesting read, and a fascinating story.
January 16, 2015
Very good read for anyone in ops, I picked up a number of useful concepts. Will write a proper review later.
Displaying 1 - 13 of 13 reviews