MAY 2024AEROSPACEDEFENSEREVIEW.COM8In My OpinionORGANIZATIONAL SAFETY IN AVIATIONBy Jamie Johnson, Regional Director of Civil Aviation, Transport CanadaAviation accidents are rarely just the results of the actions of an individual or the failure of a single system. Usually, they are caused by sequences of events that have their genesis in organizational culture.Whether I knew it or not, I have been in the safety business since first arriving on an operational Royal Air Force (RAF) Tornado GR1A Squadron in 1991. However, I don't think I had ever really considered aviation safety in the organizational sense until January 2005, when I found myself 25 miles Northwest of Baghdad, Iraq, beginning the accident investigation into the tragic loss of Hercules aircraft XV179. At the time, it was the UK's biggest single loss of life during Op Telic. Sadly, only 20 months later, Nimrod XV230 crashed 10 miles South East of Kandahar, Afghanistan, with the loss of all 14 crew members. During the investigation into the loss XV179, we were drawn to the conclusion that the aircraft had been lost due to enemy action, but there were many indications of an overstretched organization and a degradation of the wider airworthiness system. However, in the case XV230, the internal investigation concluded the loss had been caused by airworthiness issues resulting in a dry bay fire, leading to a subsequent independent inquiry that focused on organizational issues.Led by Charles Haddon-Cave QC, the Nimrod Review was published in October 2009 and is available in the public domain. If you are a senior leader in the aviation industry, then the Nimrod Review is an essential read, not just because of the consideration of events surrounding XV230 but also because Haddon-Cave revisits other major inquests into accidents with organizational causes.While I wholeheartedly agree with the analysis and conclusions of the report, as somebody who was there After a 20-year career as an Engineer Officer in the Royal Air Force, Jamie spent the next ten years as a Program Director in the aerospace industry, working for Marshall Aerospace and the IMP Group. He became Regional Director for the Pacific Region in 2018. Jamie holds an MSC in aircraft design and lives with his family in Victoria.Jamie Johnson
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