On 2 September 2006, all 14 crew of a UK Royal Air Force (RAF) ‘spy plane’ Nimrod XV230 were lost following a catastrophic mid-air fire. The aircraft was on a routine mission when a leak of aviation fuel, shortly after air-to-air refuelling, came into contact with a source of ignition. The fire was not accessible, not able to be remotely suppressed, and the incident was not survivable.
‘The Nimrod Review’, led by The Hon. Mr Justice Haddon-Cave, is a model investigation, and should be required reading for executives and leaders in all industries. The Review takes the aircraft fire as its starting point, but casts its net far and wide through the organisation, as well as considering relevant events in other industries.
This Nimrod XV230 tragedy is so rich in lessons, Martin Anderson, Chartered Human Factors Professional, shares on his website a series of articles about the Nimrod XV230.
What can you learn from the Nimrod disaster? At a superficial level, the specifics of this event were unique, but by delving deeper into the ‘why?’, the Review team revealed that history does in fact repeat itself.
Nimrod XV230: Parallels with healthcare. By discussing the relevance of the Nimrod XV230 event to healthcare, Martin aims to illustrate that the organisational lessons from this event are applicable to almost any industry. There are parallels with several major healthcare events.
Success, complacency and failure. The track record of the Nimrod aircraft led to a high level of confidence in the safety of the fleet, and this impacted on the quality of safety assessments. In this article Martin refers to many other incidents where past successes, together with a failure to effectively act on warnings, contributed to disaster.
Normalisation of deviance. Martin explains what this term means, why it’s important and how it can be countered. In relation to the Nimrod XV230 incident, fuel leaks were seen as inevitable. As in other organisations, small deviations from the norm, gradually become the norm. This ‘new normal’ then allows further deviance to become acceptable, a new baseline is created and the organisation shifts what it perceives to be acceptable. In the article, he lists a set of questions for you to consider, to help you identify and manage inappropriate deviations before they become the new normal.
Change is the only constant. The Nimrod Review refers to organisational trauma and a tsunami of cuts and change. Organisational change may be inevitable, but it does not have to lead to disaster. Companies often fail to consider the cumulative impact of successive changes, simply focusing on individual changes in isolation.
Keep it simple. The author of The Nimrod Review, The Hon. Mr Justice Haddon-Cave, states that simplicity is your friend and complexity is your enemy.
Ten questions on organisational failures. Martin provides ten questions to help stimulate discussion and reflection. These questions are based around the three topics of leadership, culture and priorities.