View Full Version : While we were sleeping.....

Captain Sherm
3rd Nov 2009, 00:04
On this forum we collectively and at times with passion, meander around arguing about mis-loaded bags (happens every day somewhere on many carrier good and bad), conditions and strategies and yield management and LCCs etc etc etc.....

But back in the real world.....over on the Military Forum there's a thread running about the very recent report on the crash of an RAFG Nimrod in Afghanistan about 3 years back. As a stunning indictment of how cultural change can in fact be a creeping organisational suicide it ranks with the Presidential report into the Challenger disaster of 25 years back.

As professionals we should all carefully read the Nimrod report and ensure we take where we can, the key lessons into our daily personal and professional working lives, in AIPA/AFAP technical and safety committees, in the questions we ask at "Road Shows", in the entries we make in the Tech Log, in our responsibilities as PIC for the whole of the flight etc etc etc.

If we don't focus our efforts into this most fundamental of issues we will continue to lose not just working conditions, but our role as the final gatekeepers of public safety. We can no longer say that "Management (including CASA) run the show, we fly the planes". We can't trust that KPIs, spreadsheets, powerpoint presentations and new buzz words will guide our world.

Read this:

"Mr Haddon-Cave condemned the change of organisational culture within the MoD between 1998 and 2006, when financial targets came to distract from safety.
He quoted a former senior RAF officer who told his inquiry: "There was no doubt that the culture of the time had switched.
"In the days of the RAF chief engineer in the 1990s, you had to be on top of airworthiness.
"By 2004 you had to be on top of your budget if you wanted to get ahead."

If you google 'Independent review into broader issues surrounding loss of RAF Nimrod in Afghanistan in 2006" you'll be able to download the report. Spend a few bucks and print off a copy and carry it with you for a while.

There was a world of technical and operation excellence but I fear it died long ago, probably the day our CAA finally retired its last aircraft. It will take some personal and collective strength for each of us to take up that slack and look management in the eye and ask if they've read AND digested the Nimrod report. Anyone of them who hasn't or won't stands damned professionally.

When I next get home I will print off a couple of hard copies and send them to the senior management people I know in QF, VB and JQ and CASA. If many others do the same it might be a good wake up call. A lot of the "new" management assume that all their precious flow-charts and systems will always keep the punters safe. If we don't tell them that the "Emperor has no clothes" who will?

Disco Stu
3rd Nov 2009, 00:52
I've been reading this document for the last few days (and being interupted by work!)

I can say that this investigation by Haddon-Cave QC has established a standard for future investigations that will be hard to achieve, let alone better. I would kill for the ability and resources to be able to produce a report as he has.

Should we (and we should) look at Government Departments, National Regulators, Airline Managements and ourselves as Haddon-Cave QC has done then I fear we will all be found wanting.

I for one, hope this wake up call to (in particular) the bean-counters of the world is recognised, regretably I doubt whether they understand that there is a real world outside a P & L sheet or whatever they get all hot and sweaty about.

The contents I have read thus far are actually not surprising, what is surprising is that it has taken this long for somebody to document them.

Haddon-Cave QC has done us all a serious favour, thank you Sir.

Disco Stu:ok:

3rd Nov 2009, 01:03
Document (in pdf or hardcopy) available here:

The Nimrod Review (http://www.official-documents.gov.uk/document/hc0809/hc10/1025/1025.asp)

3rd Nov 2009, 08:38
Sounds eerily similar to what happened with NASA and certainly with Qantas..

Roller Merlin
4th Nov 2009, 13:13
Unfortunately the summaries in the Nimrod case are a familiar story, and seem to be bubbled up again every time there is a major accident. The public wants answers on why these deaths occurred - and a fix it so it never happens again. The public does not want to hear about profits or benefits or stats or KPIs, only reasons for the tragedy and who to blame if it is due. The reasons are common- staff turnover, lack of expertise, dumb paperwork exercises, process for process sake, rules and more rules, continuous change for improvement. Recommendations are largely the same: Simplify+empower the responsible, use principles more than rules, keep experienced and knowledgeable people+add leadership+support the workers+build a listen-and act-culture. The reality is that most modern businesses oppose a return to these good principles in a relentless drive by their shareholders, boards and CEOs for profit. And governments are forcing more business practices into the public services. Recommendations like these ones cost money, so cut them! Churn keeps wages low, seek continued cost cuts, short term gains and agility is good! Bollocks.

Many of these criticisms made of systemic failures in the RAF and MOD can be mirrored with our own ADF bureaucracy, especially in the "business processes of DMO, and the continual "bureacracy-building" processes. The Howard Government's legacy procurement process is a classic example that means it now takes 7-10 years to replace a simple training aircraft, created the Seasprite debacle of $1Billion wastage, just to name a couple. I understand that DMO now has more people involved than Army Land Command, so there are more pen pushers than gun toters to save governments from embarrassment with their piles of paper. Senior ADF leaders have often been disempowered to make real change, so there is a lack of leadership and lots of ass covering pending the next promotion. Similarly CASA is being driven by the lawyers where tomes of regulations make everything better. The operators and leaders are overridden by the rule-makers and spin-prophets to protect their ministers. Eventually the paper processes become so convoluted that the humans cant work within.

This report suggests that a bureaucratic explosion occurs, and that a return to "old fashioned" principles and simplicity will save us all. I certainly dream of that day.

5th Nov 2009, 01:32
The reality is that most modern businesses oppose a return to these good principles in a relentless drive by their shareholders, boards and CEOs for profit.

This is not going to change! This has been human nature for the entire history of humanity!

Those "good principles" cost good money. Return to them and you will not be competitive - you will put all your employees out of work.

That "relentless drive for profit" has been a very good thing for millions of the worlds people. Millions have a higher standard of living now than they did 50 years ago - and they can now travel on airliners!

Any call for a return to conditions of 20-50 years ago is a waste of time.