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

• 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

Winner of the George Terry Award "The reader will be fascinated... The conclusion is eye-opening and the 'lessons learned' are insightful... A lucid and well-argued book that is a must-read for anyone seeking to comprehend the complexity of fratricide."--John Davis, Air Power History "Friendly Fire is a deeply intriguing analysis of a highly complex incident that resulted in needless deaths... Drawing on an extensive knowledge of systems theory and organizational behavior, [Snook] weaves an account of an organization on the edge of chaos, a nearly deterministic system ultimately responsible for the resultant loss of life. His conclusions are as disturbing as they are fascinating... Snook paints a disconcerting picture of the potential pitfalls of organizational complacency that every military professional should take to heart... A concise, well-written account of human tragedies... Snook presents a thoroughly analytical, yet exceptionally unambiguous, narrative of the events that ultimately led to the deaths of 26 peacekeepers. Any research into this incident would be incomplete without the information [this] author provide[s]."--Steven Leonard, Military History

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

• 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

Winner of the George Terry Award "The reader will be fascinated... The conclusion is eye-opening and the 'lessons learned' are insightful... A lucid and well-argued book that is a must-read for anyone seeking to comprehend the complexity of fratricide."--John Davis, Air Power History "Friendly Fire is a deeply intriguing analysis of a highly complex incident that resulted in needless deaths... Drawing on an extensive knowledge of systems theory and organizational behavior, [Snook] weaves an account of an organization on the edge of chaos, a nearly deterministic system ultimately responsible for the resultant loss of life. His conclusions are as disturbing as they are fascinating... Snook paints a disconcerting picture of the potential pitfalls of organizational complacency that every military professional should take to heart... A concise, well-written account of human tragedies... Snook presents a thoroughly analytical, yet exceptionally unambiguous, narrative of the events that ultimately led to the deaths of 26 peacekeepers. Any research into this incident would be incomplete without the information [this] author provide[s]."--Steven Leonard, Military History

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

• 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

Winner of the George Terry Award "The reader will be fascinated... The conclusion is eye-opening and the 'lessons learned' are insightful... A lucid and well-argued book that is a must-read for anyone seeking to comprehend the complexity of fratricide."--John Davis, Air Power History "Friendly Fire is a deeply intriguing analysis of a highly complex incident that resulted in needless deaths... Drawing on an extensive knowledge of systems theory and organizational behavior, [Snook] weaves an account of an organization on the edge of chaos, a nearly deterministic system ultimately responsible for the resultant loss of life. His conclusions are as disturbing as they are fascinating... Snook paints a disconcerting picture of the potential pitfalls of organizational complacency that every military professional should take to heart... A concise, well-written account of human tragedies... Snook presents a thoroughly analytical, yet exceptionally unambiguous, narrative of the events that ultimately led to the deaths of 26 peacekeepers. Any research into this incident would be incomplete without the information [this] author provide[s]."--Steven Leonard, Military History