I was President of the Independent Service Inquiry into the fatal accident of a member of the Royal Air Force Aerobatic Team (RAFAT), the ‘Red Arrows’.
The pilot died as a result of injuries sustained when his ejection seat fired accidentally prior to take off and his parachute failed to open.
The incident was a shock to the Royal Air Force and to the wider community, as well as a tragic personal loss for his family and friends.
I worked on the investigation full time for 18 months and left no stone unturned in identifying the factors that contributed to the accident.
The report I authored was the primary source of evidence at the Coronial Inquest and I was the primary ‘witness’. The report identified a wide range of contributing factors and made many recommendations, all of which have since been implemented.
The investigation was a pivotal learning experience for me.
The ‘Red Arrows’ are one of the most famous aerobatics teams in the world – yet this accident shows that even the highest performing teams are susceptible to strategic failure. Was the team’s renowned excellence in the air carried through to preparation and risk management across all the processes on the ground? Although there were many lessons learned through the Inquiry, one element which has since become central to my approach was what it highlighted about workplace culture, as this was one of the areas where significant failings occurred.
As a result of this Inquiry, the vital importance of workplace culture has been seared into my DNA and is now at the heart of my methodology and thought processes. I have experienced first-hand the extraordinary effect it can have on people and organisations. At its best, it can inspire and support people to achieve amazing things whilst in the case of this accident, workplace culture can also play a significant role in an unnecessary fatality.
The investigation into the ‘Red Arrows’ culture highlighted that the team may have become too inward looking and that ‘groupthink’ may have prevented sufficiently objective and critical assessment of some crucial processes and operations, with gradual ‘organisational drift’ occurring over a number of years. The Convening Authority agreed that shortcomings in standards, risk management and supervision had arisen and that cultural factors probably ‘gave oxygen’ to their divergence from established practices seen elsewhere.
Although this was part of the conclusion, it is worthwhile to pause and consider one important question:
As a fighter pilot myself, would I have acted any differently if I had been part of their workplace at that time? Or would I too have been influenced by the prevailing culture and become part of it, without being critical or questioning? Of course, it is impossible to say for sure, but on reflection and understanding the power of culture as I now do, I think it highly likely I would have acted in exactly the same way.
It is only by standing back and being objective that it is possible to assess clearly whether an organisation is performing at its best or whether its culture needs changing. A healthy workplace culture must be able to shine a light on itself and continually question the way that things are done if it is not to become complacent, regardless of perceived performance. That ability to stand back and be objective is an important part of leadership.
‘Black box’ type investigations tend to focus on the quantitative data and set out to answer the question ‘What happened?’ Whilst this is important, the most vital question to ask is ‘Why did it happen?’ Only by understanding ‘why,’ are we able to improve and grow as an organisation and to act on learnings related to deeper cultural issues that have a lasting effect.
Workplace culture can literally be a matter of life and death. Now I have seen how even the highest performing teams can fail, and witnessed up close the grief such failure can cause, I am driven by a fierce determination to do all I can to help organisations create sustainable cultures which are positive and safe, where people can thrive and fulfil their potential.