List of Figures ix
Preface xi
Acknowledgments xiii
List of Abbreviations xv
1. Introduction: How In the World Could This Happen? 3
Motivation: To Learn from and Correct Our Mistakes 7
Theoretical Domain: A Normal Accident in a Highly Reliable Organization 10
Data: We Know Exactly "What" Happened 15
Analytical Strategy: Constructing a Causal Map 18
Outline of the Book: An Explanation Across Levels 22
2. The Shootdown: A Thin Description 26
Background: Context Is Important 26
Command and Control: Dense Webs of Crosscutting Guidance 31
The Players: SAVVY, COUGAR, MAD DOG, DUKE, EAGLEs, and TIGERs 40
The Shootdown: A Deadly Dance 52
Multiple Explanations: A Walk Through the Causal Map 65
3. Individual-Level Account: Why Did the F-15 Pilots Misidentify the Black Hawks? 71
Making Sense: Seeing Through the Mind's Eye 75
Ambiguous Stimulus: What Did They Actually See? 76
Expectations: What Did They Expect to See? 80
Desire: What Did They Want to See? 94
Summary: Why They Saw What They Saw 96
4. Group-Level Account: Why Did the AWACS Crew Fail to Intervene? 99
A Weak Team: Overmatched 104
Diffuse Responsibility: When Everyone's Responsible No One Is 119
Summary: The Fallacy of Social Redundancy 135
Organizational-Level Account: Why Wasn't Eagle Flight Integrated into Task Force Operations? 136
Differentiation and Integration: Whatever You Divide, You Have to Put Back Together Again 143
Interdependence: Multiple Failures to Coordinate 152
Summary: How It All Came Apart 177
6. Cross-Levels Account: A Theory of Practical Drift 179
Practical Action: A Core Category 182
Practical Drift: A Theory 186
7. Conclusions: There But by the Grace of God 202
On Theoretical Reminders: Normal Behavior Abnormal Outcome 204
On Practical Drift: Or Is It Sailing? 220
Implications: Let's Build a Library 232
Appendixes
1. Method 237
2. Friendly Fire Applied: Lessons for Your Organization? 239
References 241
Index 251

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.

United States Army LTC Scott A. Snook serves as an Academy Professor in the Department of Behavioral Sciences & Leadership at the United States Military Academy. He also directs West Point's Center for Leadership and Organizations Research.