Cultural traits and organizational practices detrimental to safety were allowed to develop, including: reliance on past success (such as tactics) as a substitute for sound engineering (or dynamic threat and risk analysis) practices (such as testing to understand why systems were not performing in accordance with requirements); organizational barriers that prevented effective communication of critical safety ( equipment , intelligence) information and stifled professional differences of opinion; lack of integrated management across program elements; and the evolution of an informal chain of command and decision-making processes that operated outside the organization’s rules (non compliance to XXXXX and proper risk management from higher command)
I have cut and pasted this quote from the Nimrod page, apologies for stealing.
I feel so strongly about the lack of Risk Management and its relevance to the loss of XV179 that I can no longer remain compliant or conform to the processes of justice that exclude this as an issue. As it stands, the public consensus that Aviation Risk Management and/or Mission Risk Profile are not relevant or specific to this crash is simply unacceptable to me.
The BoI in so many ways did a laudable job, under the most challenging and emotional circumstances. It is excruciatingly difficult for me to be critical but this is about the process and not the people. The three identified contributory factors identified (perhaps there should have been more) are broad ranging and yet they were largely discussed in isolation, perceived as unforeseeable and summarised the crash as a one off. I argue it was an incident waiting to happen and I find it difficult that these factors were not considered from a systemic perspective. I strongly believe that the crew were let down by the absence of firm direction from higher command, HQ 2 Group, HQ Strike Command, Air Component Command Al – Udeid (to name a few) and that inappropriate /inadequate risk analysis was undertaken to justify operations. Unfortunately valuable debate was stifled when there was opportunity. It is now incredibly complicated and near impossible for me to get this on the table, let alone in the venue where the ‘issues’ will be discussed and hopefully lessons learnt identified. I am disappointed that the consensus, thus far is simply that, a consensus “things are/were fine” and I just wish someone had the balls to think and speak outside the box! Perhaps somewhere behind closed doors, a critical rethink has taken place and improvements have been made? If so were some of these issues mentioned? is there a blurring of how OP Telic and OP Crition missions are undertaken? What is the definition of operation imperative and is it open to misuse, to get a job done? Is the role, skills and resources of ‘The Flight’ mismanaged by higher command? Just to name a few.
The only subtle opening into debate was lent by the AVM, who in his summary commented, that there seems to be a cultural skewering of tactics towards low-level daylight flying. Is he suggesting that just because you get good at something you don’t need to apply it all the time? This suggests one interpretation and may I add caution and disagree with those who interpret this as a judgment of the crew, it simply is not! May I be so bold to add, to self- authorise or not self-authorise, that is a contentious question. As it stands one of the flaws of self-authorising is that higher command can cop out of responsibility to crews who operate in high demand enviroments, perhaps higher command concentrate\prioritise getting their jobs done rather than have responsibilty and focus on how the job gets done?
Infact, one can argue, the lack of ESF is indeed inclusive and manifested from poor judgment, proper risk analysis and management. I suspect that the MoD in closing will argue that had it been installed they cannot say it would have saved the crew. I would argue differently however what they can’t disagree with is that this crew deserved the fighting chance ESF would have given.
Thank you to all those, RAAF, USAF and RAF who have put up with my terrier like qualities when it comes to making sense of Paul’s crash. To those simplistic, morons who say it’s about monetary gain and apportioning blame, you have no idea. It’s about honoring Paul’s loss from a personal and professional context.
Paul’s death certificate may read killed in action and I can’t bring him back but it’s the lack of action that can be learnt from and changed, to prevent future devastation.
There I've said it and feel totally sick for doing so. After almost three years of writing letters and submissions to not be addressed in an equitable forum, I feel disappointed and disillusioned.
Anyway, I quote, with a tear and smile "Kell, I'm not here for a haircut."
I wish you all a safe and peaceful Christmas!