The Australian’s government’s report into the crash of a Blackhawk helicopter on the deck of the HMAS Kanimbla in November 2006, in which two defence personnel were killed, has been released by Air Chief Marshal Angus Houston.
According to media statements
“The principal and overarching finding of the Board of Inquiry was that the cause of the crash of Black Hawk 221 was pilot error by the aircraft captain,” Air Chief Marshal Houston said. “Justice Levine stated that the principal finding, however, could not be viewed in isolation nor blame attributed to a highly experienced and well-respected Black Hawk pilot.
“This accident was the regrettable result of a number of factors coming together which culminated in this tragic incident. There was a gradual adoption of approach profiles which, on occasions, exceeded the limits of the aircraft. Other factors included a ‘can do’ culture in the Squadron, inadequate supervision, the pressures of preparing for operations, the relocation of the Squadron and a high operational tempo.”
Amongst the control measures introduced following the Blackhawk 221crash and an earlier incident, the Army issued a new risk-management policy in October 2007. It provides “commanders with clear instructions on how to conduct risk management on operations and in training.”
Ultimately, good has come from the results of the Blackhawk crashes. The decision to release this report, provide audio of the press conference and considerable inquiry background, is commendable. However, as reflected in the Air Chief Marshal’s comments above, and expanded upon in the must-hear podcast (35Mb MP3), safety management standards had slipped over time. He is keen to emphasise that the crashes need to be seen in a broader organizational context, as any incident investigation should.
But, in my opinion, that broader context remains damning. The Defence Forces should, through their strict hierarchical system and regimented decision-making, be an exemplar of safety and risk management.
It is always the case that we should learn from our mistakes but it seems, as in the private sector, that those organizations with considerable safety resources who are best equipped to avoid problems continue to experience them.
With many workplace investigations the excuse for incidents that is frequently trotted out – poor safety culture – is becoming a term of reduced relevance. The failure of a safety culture is not an “act of God” although the phrase, safety culture, is being used in the same manner. It implies that there was only so much that could be done but it also indicates that prior to any incident not enough was done.
Safety improvements through hindsight have become the mainstay of contemporary management. If there is a stuff-up, acknowledge the fact and promise restitution. Don’t accept responsibility. Don’t admit liability. In fact, don’t mention the incident, only mention what improvements one intends to make.
The depressing part of a no-blame investigation is that it can feel so unsatisfying.