MAY 2024AEROSPACEDEFENSEREVIEW.COM9at the time, I can see that it is very much the viewpoint of somebody on the outside looking in rather than the inside looking out. In aviation, we are often victims of our own success, having achieved remarkably low accident rates. This can lead us, if not to complacency, then at least to an assumption that we are `safe anyway'; a kind of success that has engendered optimism. Hadden-Cave became a little too focused on the failures of individuals and a general malaise in the system. In my experience, it's not quite what I have seen, either in civil or military aviation. In practice, a `can do' attitude and a willingness to continue to operate with an over-stressed system are usually the better places to look for the root causes of organizational accidents. At the time of the loss of XV230, we were simply spread too thin and fighting on too many fronts, but it is easy to draw parallels to today's civil aviation industry grappling with both pandemic recovery, marginal economics, and a widespread skills shortage. In aviation, leaders can be drawn away from safety as they focus on other priorities necessary to steer their organization through difficult circumstances; there is no great Machiavellian plot to ignore safety nor any lack of overall effort by leaders. The staff becomes solution-focused, working with what they have to support the operation, and deviations to safe working practices simply get normalized. Training takes a back seat to operational delivery, and skill levels drop, further impacting safety (it is wrong to assume that aviation safety is exclusively a data-driven science; a good part of it will always remain a judgmental exercise very much dependent on very human skills and experience). Eventually, leaders simply become detached from operations and lack an up-to-date understanding of developing safety problems, while at the same time, staff may be very aware of the issues but become resigned to the fact the leaders are unlikely to act on their advice and simply retreat into blind acceptance of their situation. To me, it's this breakdown of communication between senior leaders and staff that is often behind aviation accidents. Hadden-Cave's conclusion that the loss of Nimrod XV230 was attributable to the failure of leadership, culture and priorities was a very succinct summation of the situation and something that all aviation leaders should learn from, even if some of his assessment of the role of individuals was a little melodramatic for my tastes and perhaps not entirely fair.If, as an industry, we want to learn from our past mistakes, we should all heed the words of James Reason, who stated "If you are convinced your organization has a good safety culture, you are almost certainly mistaken." As leaders, we have to begin with an assumption that both our safety systems and safety culture can and should be improved. We are never safe enough, nor should we ever sit back and point at low accident statistics as a justification for diluting our safety systems. Moreover, we must actively challenge ourselves to deliver those improvements at every level in our organization; the relationship between the staff who have the current understanding of the operational situation and leaders who have the authority to campaign change is absolutely fundamental to aviation safety. Accident investigation scene 2005IF AS AN INDUSTRY WE WANT TO LEARN FROM OUR PAST MISTAKES, WE SHOULD ALL HEED THE WORDS OF JAMES REASON, WHO STATED THAT IF YOU ARE CONVINCED YOUR ORGANIZATION HAS A GOOD SAFETY CULTURE, YOU ARE ALMOST CERTAINLY MISTAKEN
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