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Old 11th May 2012, 13:55
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Engines
 
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There are a number of issues around 'Air Safety' and 'Just Culture' being pushed around here. Perhaps this view might help.

'Just Culture' is a relatively recent arrival on the 'Safety' scene, and not a bad one, in my view. You can't argue with its aims and objectives, nor its key features. However, at the end of the day, it is just a statement of values and cultures, which then have to be implemented by an organisation.

That's where this discussion might have got caught. I think that there are MANY organisations involved in generating 'safe aviation', and they all have to deliver a 'just culture' in the way that they need. One size will never fit all. However, many of them have to work together.

Starting at the top is always a good military way to look at it, and we now have (for better or worse) an active MAA laying down regulations and ensuring compliance. However, it's my view that the MAA's main focus should really be at the higher levels, such as DE&S and the higher areas of MoD, where Tuc so clearly shows the failings of previous years. This is really important when aircraft and weapons are being procured, developed and brought into service. Honestly though, I'm not sure that looking to 'just culture' to overcome years of secrecy and obfuscation is profitable. I agree with Tuc that you just need basic technical and managerial competence to be restored.

Once you leave those areas, you get to the operational commands, or for shorthand, RN, Army and RAF. 'Just Culture' really has to work here, often driven by the Services' own Flight Safety organisations, who are implementing not only MAA directives but also single service policies. I've worked with all three, and I know that the RN and the Fleet Air Arm have had an active and not at all complacent Flight Safety system for many years. I first heard 'Just Culture' mentioned in the RN around 11 or 12 years ago, and it's been heavily promoted since then, with strong leadership from the 2 star operational command, flowing down to stations, ships and squadrons. My own first hand experience of RAF 'Flight Safety' was not entirely positive, as (again my view), Strike were content to mainly leave 'Flight Safety' to their separate Inspectorate of Flight Safety (IFS), which had the effect of diluting the 'safety' and 'just culture' angle from the mainstream day to day activity of the Command. But, just my view from working there. Probably better now.

In the end, I suppose what I'm trying to get over is that 'just culture' has to be actually 'done' at all levels in a number of organisations - relying on MAA to 'deliver' it is not realistic. It also depends on good leadership, openness and honesty. If (like I had in 28 years in the RN) you have that, there's not much you can't achieve. I honestly believe that the RAF's 'pilot centric' culture, while fully understandable, is not always the best way to deliver the leadership and competency sets 'just culture' needs. It demeans the role of the engineer (and any other non-pilot role) and can sometimes promote officers who have little or no understanding of 'just culture'.

Finally, the issue of 'blame'. Just culture is clear, there is no room for playing a 'blame game'. What there has to be is clear accountability, backed up by sufficiently independent investigations and analysis. Here's a bit of a problem, because while I understand the objections raised to MAAIB being part of MAA, it gets harder to see where a really effective MAAIB would sit within Government. My view, and mine alone, is that it has to be linked to the Defence Safety Board, but that it must be carried out by people with sufficient current experience and technical ability to be able to conduct really effective investigations in war zones if need be. That means Service and civilian personnel. The RN's FSAIC concept (AIU collocated with Flight Safety Centre but separate) was actually praised by Haddon-Cave and then dismantled by MAA. Go figure. Again my own personal view is that the location of MAAIB within MAA, and more importantly, the largely RAF construct adopted for Service Inquiries are not at all optimal and will have to change in the future. They link the MAAIB far too closely to the MAA and also tie the role of the investigators too closely to the conduct of the Inquiries.

Put simply, everyone in the system has to have complete trust in the investigators to be thorough and completely independent. They also have to have trust in the way that Service Inquiries are conducted and their findings discharged. I think we still have the first, just. I just don't think that we have the second.

Best regards as ever

Engines
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