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The challenges of an Air Safety culture and delivering air power

In 2006, UK forces lost fourteen crew and a vital aircraft to a fire whilst in flight on operations in Afghanistan. This was the biggest single loss of life of British service personnel in one incident in theatre since the Falklands War. The following year, the government appointed Charles Haddon-Cave (then QC, now Rt Hon Lord Justice) to conduct a review into the loss of the Nimrod and the broader context in which an avoidable accident had taken place. In ‘The Nimrod Review’ he found that from the Strategic Defence Review of 1998 onwards, the MOD suffered ‘a sustained period of deep organisational trauma’ due to financial pressures, reorganisation and distraction. The recommendations of Review were extensive and aimed to rectify ‘manifold’ shortcomings in the MOD’s airworthiness system. Ever since, the RAF has worked to back up its systems and procedures with an enhanced Air Safety (AS) culture that minimises accidents across operations and training.

Today, the RAF operates in a wide range of challenging environments, including combat zones, search and rescue, and humanitarian missions. The complexity of these operations makes AS critical to ensuring the protection of personnel, assets, and the successful execution of missions. Similarly, the RAF utilises advanced aircraft and systems that require strict adherence to safety protocols, detailed by each platform’s safety case, to mitigate risks associated with their use. The RAF collaborates with international and industry partners, sharing best practices and learning from other air forces to enhance safety standards.

Learning from disaster

AS and warfare are two distinct but interconnected aspects of military aviation operations. AS focuses on implementing robust Safety Management Systems (SMS). A SMS details the management of AS, through accountability, policies, and procedures and a focus on AS culture. The RAF’s SMS was amended in response to The Nimrod Review by changing its approach to safety culture. After the incident the RAF conducted its own 7-month long internal Board of Inquiry (BOI) to determine the potential route cause as to why the event occurred. The BOI then highlighted some recommendations form its own investigations; these were surmised and agreed within Ch.3 of The Nimrod Review. The BOI concluded that the loss of XV230 was caused by:

…The escape of fuel…occasioned by an overflow, causing fuel to track back along the fuselage, or a leak of fuel from the fuel system, leading to an accumulation of fuel....the fuel leak could have been caused by a hot air leak damaging fuel system seals…– Charles Haddon-Cave, Nimrod Review, 2009

The possibility of this event could have been prevented by the Nimrod Safety Case (conducted 2001-2005) but this was not captured or mitigated appropriately. Since then, British military aviation adopts the principle that if a positive AS culture is not installed then the Risk to Life will be compromised. Consequently, as stated in The Nimrod Review, the RAF fosters a ‘Just Culture’ which:

strikes a sensible balance between a ‘blame culture’ and a ‘blame-free culture’, i.e. between holding people properly accountable for their acts or omissions and ensuring the right lessons are learned for the future.– Charles Haddon-Cave, Nimrod Review, 2009

The RAF, with other air forces, prioritises the implementation of robust SMS to ensure the protection of personnel, assets, and the successful execution of missions in line with ICAO standards and best practices. The commitment to safety extends to all aspects of aviation operations, including aircraft maintenance, operational planning, and training exercises. By integrating safety considerations into these areas, air forces mitigate risks and promote a secure operational environment.

The balancing act

AS can impact the cost of equipment if they are not operated appropriately. The duration of warfare is primarily influenced by strategic objectives and the overall dynamics of the conflict. A positive AS culture does not negatively influence operations.

The issue that underpins the break down within AS SMS will seldom be from processes or equipment, which aren’t infallible, but will generally come from the human operating them. This is known as Human Factors (HF) and education on this is delivered to RAF personnel via a continuous awareness training package, mandated within RA1440, and as recommended in The Nimrod Review. CAP 719 states:

1.1 Human behaviour and performance are cited as causal factors in the majority of aircraft accidents– Charles Haddon-Cave, Nimrod Review, 2009

HF training is designed to increase individual and team performance, increase safety, and help to reduce errors by removing inefficiency. Ultimately, the lessons identified within an AS culture can drive up standards across the aviation sector through information sharing, thus promoting a positive and safe working environment that also drives down costs, including Risk to Life.

AS within the RAF has a direct impact on current and future military operations. The established standards and norms enhance mission effectiveness by ensuring that personnel and aircraft are protected. Safety considerations are incorporated into the design and development of new aircraft, systems, and technologies, through their Safety Cases. By prioritising safety from the outset, the RAF and industry partners ensures that future capabilities will have built-in safety features, enabling safe and effective operations.

Conclusion

In summary, the British military suffered a huge loss of personnel and asset when Nimrod XV230 crashed. Since the Haddon-Cave report the RAF has implemented a positive AS culture through its ‘Just Culture’. This also has a positive outcome for mission success, as errors are less likely to occur through collective learning, captured within appropriate reporting, so to reduce the risk of the event from happening again. Similarly, a positive AS culture may not necessarily negatively affect a mission outcome, from the perception of being ‘too safe’ or ‘risk adverse’ to accomplish the goal, as there are acceptable levels duty holding of risk and mitigations to ensure that a potentially dangerous event is as low as reasonably possible (ALARP) and tolerable. However, it may be the human operator that may let the system down, through no fault of their own, but from natural human performance limitations referred to as Human Factors. The future of AS within military operations is captured early within the design of new systems, thus maximising success of their intended use and overall effect on the mission driving standards and dramatically reducing costs.

 

The Freeman Air and Space Institute provides independent and original research and analysis of air and space power issues. Based in the School of Security Studies, the Freeman Institute places a priority on identifying, developing and cultivating air and space thinkers in academia and industry, as well as informing and equipping air and space education provision at King’s and beyond.

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