Thursday 29 October 2009

Insufficient leadership

Predictably, the media are giving heavy coverage to the "Nimrod Review" into the wider issues surrounding the loss of Nimrod XV230 in Afghanistan on 2 September 2006, commissioned by former defence secretary Des Browne on 13 December 2007, and delivered yesterday by Charles Haddon-Cave QC.

The piece by Michael Evans, in The Times is, for instance, headed: "Nimrod report is most devastating in living memory". It reports that the accident occurred because of years of complacency, safety reviews that were riddled with errors and a general lack of care towards the personnel who had to fly the aircraft in a dangerous environment.

What Evans does not say – and neither, it seems do many other journalists – is that the report is 587 pages long, packed with detail by a man who is an aviation specialist, a fact that is very apparent in the depth and breadth of the findings.

Given the necessary speed with which the media must work, and the fact that Haddon-Cave did not release his report until after the press conference, this means that none of the journalists who have filed their stories for the main news organisations – all of which were up in the early afternoon and evening – can have read the report.

Most will have read the executive summary and relied on the press releases. But even then, with such a detailed report, there is much scope for "cherry picking", a tendency which is very evident as difference newspapers chose their own slants for their stories. Thus we see The Daily Telegraph leader home in on the "culture of penny-pinching, introduced while Gordon Brown was at the Treasury, [that] had replaced an emphasis on safety."

The same line is taken by The Guardian, which tells is that: "RAF Nimrod crash report accuses MoD of sacrificing safety to cut costs", and even CNN leads with "Budget focus cited in '06 British air crash".

Other newspapers and media organisations choose their own "lines", their particular points of focus, and therein lies the inherent distortion which makes none of the accounts either reliable or informative. Effectively, by omission, they distort the report – and in so doing miss completely the thrust of what Haddon-Cave has to say.

One can understand, of course, why this might be, and Haddon-Cave does not make it easy, as the essential "framing" which provides the intellectual basis for the report is buried deep within the text, shrouded in its own jargon which requires considerable study for it to become clear.

"A large proportion of accidents," he writes (including this one) "require the timely concatenation of both active and latent failures to achieve a complete trajectory of accident opportunity." He then goes on to explain that "latent" errors are those whose adverse consequences may lie dormant within the system for a long time. "Active" errors are associated with "front line" operators of a complex system, such as pilots, whose effects are felt almost immediately.

The essence of this accident, we learn from the comprehensive analysis, was the concatenation of multiple "latent" failures, many of which were technical in nature, relating to design faults and such matters.

One cannot read the whole report, however, without coming away with the conclusion that, in the grander scheme of things, the design faults and such matters were of a lesser order, the main problem being a different category of "latent" failures. These were "flawed organisational processes", mainly within the RAF itself, afflicted with what Haddon-Cave calls "numerous pathogens hidden in the system".

Unfortunately, one has to plough through to page 473 to find these "pathogens" listed and, in the ensuing pages, they are explored in some detail, some 26 in number. And clearly, they are not listed in order of importance because only in the penultimate point does one happen upon the damning criticism that there is "insufficient leadership". Writes Haddon-Cave:

With rank comes responsibility. With responsibility comes the need to exercise judgment and to make decisions. Airworthiness judgments and decisions can often be difficult and worrying. They also can have serious consequences. Airworthiness penumbra can also be viewed as less glamorous and pressing than other matters.

For these reasons, there has been a discernable inclination by (admittedly busy) officers at all ranks to deflect, downgrade, avoid or slough off Airworthiness responsibility, judgments, and decisions either: (a) by means of wholesale delegations; and/or (b) by the outsourcing of airworthiness thinking to Industry; and/or (c) by the creation of further elaborate processes, procedures, or regulations to stand between them and the problem.

Indeed, one gets the impression that much of the process currently in place is designed not so much to improve safety, but to act as a bulwark against criticism in the event that things go wrong.

These essentially defensive avoidance mechanisms are perceived to have a number of short-term advantages: first, they get the problem off one's desk; second, they shift the heavy burden on to other shoulders; and third, they provide handy protection against any against future criticism which might be made.
As a fish rots from the head, an organisation fails from the top, and it is there that Haddon-Cave puts the finger of blame. It could have been flagged up much more strongly, although in the subtitle of his report, up on the front page is (in capitals): A FAILURE OF LEADERSHIP, CULTURE, AND PRIORITIES.

Note well, the finding that the essential function of the system had become to "provide handy protection against any against future criticism which might be made," inculcating a "tick-box" culture that we have seen in action so many times before, in other circumstances.

In a discipline that is driven by regulation, Haddon-Cave's comments on that issue are priceless, as he declares that: "Regulations are too complex, prolix, and obscure". This, he writes, "makes them virtually impenetrable and, frankly, a closed book to the majority of the congregation governed by them."

Much of the language is obscure, difficult to read, and repetitive, while the sheer volume is "neither sensible nor realistic", running to over 60 lever-arch files. This has led to the gradual marginalisation, misunderstanding, and mistrust of much of Defence regulations. "It is unrealistic," Haddon-Cave concludes, "to expect those charged with compliance to assimilate, let alone implement, many of the regulations that now exist."

What we are looking at, once all 26 points are taken on board, is a massive system failure, a system so far degraded that it is frankly a surprise that there have been so few fatal accidents. But we have seen this before as well, where it is often the sheer dedication of line personnel that make the system work, in spite of and not because of the controls.

Crucially, in contrast with the media narrative of the Armed Forces constituting the last bastion of efficiency and precision, we get a glimpse into a system which bears many comparisons with the worst of any public-sector organisation.

In a week that has also seen a critical coroner's report on the Puma helicopter crash, with accusations that the RAF base was "badly run", there is now more than enough material available to question whether the current media narrative even begins to approximate the truth. It is rare for degradation of a system to be confined to one branch, and a more critical overview might well reveal defects which are far more widespread than Haddon-Cave's lengthy but limited report reveals.

We do ourselves no favours if we buy into the media myth, and ignore that which is now becoming all too evident, that the military shares some of the dysfunctional elements which are all too prevalent in the whole of our society.