Layers of a Tragedy
MASTER SGT. JESSE BILTOFT
Headquarters and Headquarters Company
67th Maneuver Enhancement Brigade
During my first deployment to Afghanistan, my unit experienced an unfortunate mishap that cost a Soldier his life and cut short the military careers of three others. Here’s what happened. The event
Our unit had been in-country less than two weeks. We’d just completed our initial acclimatization period and had begun a movement to our assigned mission location in Kabul. The trip from Bagram to Kabul was 40 miles and would take an hour or so, depending on traffic flow. There were no vehicles assigned to my unit at this time, so our given headquarters element arranged transportation for us, which included a military police escort the entire length of the trip. In total, there were three M1097 High-Mobility Multi-Wheeled Vehicles (HMMWVs) providing convoy security and five M1078 Light Medium Tactical Vehicles (LMTVs) to move our platoon-sized element and gear. The escort elements were in charge of all facets of the convoy to Kabul. My platoon was just along for the ride.
We received a briefing from the convoy commander, loaded into the back of the designated LMTVs and waited for the movement to begin. My squad was in high spirits and ready to get underway. There were 14 Soldiers from two different squads crammed into the back of our LMTV. I recall the vehicle swaying and jerking the occupants as we traversed the winding, potholed road. The convoy speed was supposed to be 45 mph, but it felt like we were moving faster. We were about 25 minutes into the movement when the event occurred.
I felt the drop-off when the left tires went off the paved surface. The driver attempted to steer back onto the road, but he overcorrected. He then overcorrected back to the left, which is when he lost control of the vehicle. I was sitting on the short side of the fall and remember thinking to myself, "Is this really happening?" Upon impact, my M16 went flying, and my improved outer tactical vest and Kevlar helmet absorbed much of the impact on my backside. I could feel the road through the LMTV’s canvas cover as we overturned a couple of times before coming to a stop. I was dazed momentarily and could hear screaming and yelling.
I crawled out of the LMTV, found an M16 on the ground and staggered to my squad leader. He directed me to pull perimeter security while others started removing Soldiers from the wreckage and rendering first aid. My body was numb and I could barely hold my weapon. The wreck was a horrifying scene and I didn’t believe anybody would make it out uninjured. I was scared, confused and unsure what was happening. Still, leadership did its best in the aftermath of the mishap. A hard lesson to learn
After the accident, several details were brought to light. I learned the LMTV driver was inexperienced, and this was his first time operating the vehicle after receiving his license. For the convoy commander leading the movement, protocol dictated he move the procession as quickly as possible to limit exposure to potential enemy contact. That was the case on this convoy even though there were no recent attacks or intelligence to suggest this threat. For a long time, I blamed the driver for his actions that day. The more I learned about safety, however, I realized multiple failures led to this accident. The Swiss cheese model
When Army mishaps occur, investigators have several tools to determine how human factors and performance contributed. One method to identify multiple layers of failure or errors is the Swiss cheese model. Inside the Swiss cheese model, you will find the layers of failures that lead to mishaps. An accident will rarely occur when only one layer sustains a failure. When multiple layers have holes, the probability of a mishap increases significantly.
The four layers inside the Swiss cheese model are acts, preconditions, supervision and organizational influences. The act is the operational failure or the decision or failure of an individual. In the event above, the driver’s overcorrection would qualify as a direct action that led to the incident.
Preconditions usually come in environmental factors such as stress, weather issues, fatigue or physical strength. The precondition for this mishap was the road and operating environment. Operating on a winding, narrow highway with potholes, rough spots and other traffic created an environment that contributed to this event.
Next is the supervision layer, which defines the command's role in mishaps. Leaders lowering standards, allowing untrained Soldiers to operate equipment or failing to provide oversight fall into this layer. In this accident, the convoy commander was in the lead vehicle. He set the movement's pace in a vehicle with a higher top speed than the mishap vehicle. The first several vehicles in the convoy were leaving behind the mishap LMTV, which created multiple issues that set the stage for the accident. The inexperienced LMTV driver was attempting to operate the vehicle beyond his skill level. While trying to catch the lead vehicles, the movement's speed increased and contributed to the accident.
The last layer is organizational influences. This layer considers gaps that may surface when units have minimal resources or funding, personnel, excessive OPTEMPO, inadequate training or lack of procedural guidance. For this layer, the “we’ve-always-done-it-this-way” mentality applies. There was no process for risk management to determine whether the additional speed and risk were necessary. Conclusion
Again, it is rare for the Swiss cheese model to reveal only one failure in the process that leads to a mishap. This model is available for leaders to use to assess their organizations to identify areas with potential risks. Leaders need to be mindful of contributing factors and do what they can to implement a safety culture within their organizations. It is easy to see that multiple failures occurred in the incident above that all contributed to the accident. Stopping just one hole in the cheese layers might have been enough to save a life and prevent this mishap.
Shepherd, K. (2017). Predicting and Preventing Mishaps. Risk Management magazine. https://www.army.mil/article/184175/predicting_and_preventing_mishaps