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APPEA, Perth Martin Anderson 15 May 2017 NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND PRIORITIES

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Page 1: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

APPEA Perth

Martin Anderson

15 May 2017

NIMROD XV230 REFLECTIONS ON LEADERSHIP CULTURE AND PRIORITIES

This presentation contains forward looking statements that are subject to risk factors associated with oil and gas

businesses It is believed that the expectations reflected in these statements are reasonable but they may be

affected by a variety of variables and changes in underlying assumptions which could cause actual results or trends

to differ materially including but not limited to price fluctuations actual demand currency fluctuations drilling and

production results reserve estimates loss of market industry competition environmental risks physical risks

legislative fiscal and regulatory developments economic and financial market conditions in various countries and

regions political risks project delay or advancement approvals and cost estimates

All references to dollars cents or $ in this presentation are to US currency unless otherwise stated

References to ldquoWoodsiderdquo may be references to Woodside Petroleum Ltd or its applicable subsidiaries

Disclaimer and important notice

3

Introduction

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY-SA 20) Airwolfhound - wwwflickrcomphotos24874528N043901870560

+ Nimrod XV230 suffered a catastrophic mid-air fire shortly after air-to-air refuelling on a routine mission

+ Aviation fuel and an ignition source

+ Crew had no access to the fire no fire suppression system + Loss of 14 service personnel

+ Loss of the aircraft XV230

+ Loss of the Nimrod fleet

15 May 2017 4

Afghanistan 2 September 2006

Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) David Warrington - wwwflickrcomphotosben_salter839396254

5

The Nimrod Review October 2009

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Photo credit Martin Anderson copy Crown Copyright 2009

+ Shuttle Columbia

+ Petrobras P36

+ Buncefield

+ Teneriffe

+ Piper Alpha

+ Titanic

+ Barings Bank

+ Texas City

+Macondo

+Morecambe Bay NHS

+ Kings Cross

+Moura Mine

+ Ladbroke Grove

+ Herald of Free Enterprise

6

Organisational factors

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

7

Human and organisational factors in investigations

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF LEADERSHIP

+ Based on lsquoas designedrsquo not lsquoas isrsquo

+ Essentially a paperwork exercise

+ Design flaws dormant for decades not identified

+ Air-to-Air refuelling modification not assessed

+ Little operator input

+ Personnel involved were inexperienced with little knowledge of the aircraft

+ Not revisited following major accident to XV227 in 2004

+ Poor oversight of contractors by the MoD

+ Review conclusion An effective safety case would have prevented the disaster

9

Leadership 1 Safety cases

ldquoUnfortunately the Nimrod

Safety Case was a

lamentable job from start to

finish It was riddled with

errors It missed the key

dangers

Its production is a story of

incompetence

complacency and

cynicism

The best opportunity to

prevent the accident to

XV230 was tragically lostrdquo

(Nimrod Review p10)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Previous significant incidents

+ Incidents were treated as lsquoone-offsrsquo

+ Patterns not spotted

+ Systemic issues not identified

+ No lsquoread-acrossrsquo to other aircraft

+ No-one taking an overall view

+ Previous warnings about reducing resources

and increasing demands

10

Leadership 2 Warning signs

ldquoLearning disabilities

are tragic in children

but they are fatal in

organizationsrdquo (Robert L Sumwalt US

National Transportation

Safety Board)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A tsunami of cuts and change + 900 initiatives

+ Change assumed to be better

+ Huge organisational changes + lsquoPurplersquo tri-service organisations

+ Outsourcing

+ Sustained period of lsquoorganisational traumarsquo

11

Leadership 3 Organisational change

ldquoThe MOD suffered a

sustained period of

deep organisational

trauma between 1998

and 2006 due to the

imposition of

unending cuts and

changerdquo Nimrod Review p355

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ What is the purpose of your safety cases

+ How do you influence effective safety cases

+ Do you understand and challenge the work of contractors and consultants

+ What are the equivalent warning signs in your organisation

+ Do you help to lsquojoin up the dotsrsquo between previous incidents

+ Do you create learning opportunities

+ Are organisational changes (including cumulative impacts) creating unintended effects

12

A failure of leadership Reflections

ldquoIt is the thought word

and deed of leaders

that most influence the

attitudes behaviours

and priorities of

employeesrdquo (Nimrod Review p576)

As a leader you have a choice

You can negatively influence safety or you can positively influence safety

Which influence do you provide How When

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF CULTURE

+ 30 year operational history

+ Assumption that it was lsquosafersquo

+ The lsquoapparent safetyrsquo lulled many into a false sense of security

+ This undermined the safety case process

14

Culture 1 Nimrod is lsquosafe anywayrsquo

ldquoThe non-occurrence of system accidents or

incidents is no guarantee of a safe systemrdquo (Nimrod Review p181)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A culture of paper safety rather than real safety

+ Audits address processes not practices

+ Failed to acknowledge the gap between lsquowork

as imaginedrsquo and lsquowork as donersquo

+ Reliance on comforting PowerPoint

presentations rather than reading reports

15

Culture 2 Keeping it real

ldquoThere has been a yawning gap between the appearance and reality of

safetyrdquo (Nimrod Review p579)

ldquoThe actual content of

the Safety Case did

not matter as much as

compliance with the

rule which said one

must be produced

within a certain

timescalerdquo (Nimrod Review p312)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 2: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

This presentation contains forward looking statements that are subject to risk factors associated with oil and gas

businesses It is believed that the expectations reflected in these statements are reasonable but they may be

affected by a variety of variables and changes in underlying assumptions which could cause actual results or trends

to differ materially including but not limited to price fluctuations actual demand currency fluctuations drilling and

production results reserve estimates loss of market industry competition environmental risks physical risks

legislative fiscal and regulatory developments economic and financial market conditions in various countries and

regions political risks project delay or advancement approvals and cost estimates

All references to dollars cents or $ in this presentation are to US currency unless otherwise stated

References to ldquoWoodsiderdquo may be references to Woodside Petroleum Ltd or its applicable subsidiaries

Disclaimer and important notice

3

Introduction

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY-SA 20) Airwolfhound - wwwflickrcomphotos24874528N043901870560

+ Nimrod XV230 suffered a catastrophic mid-air fire shortly after air-to-air refuelling on a routine mission

+ Aviation fuel and an ignition source

+ Crew had no access to the fire no fire suppression system + Loss of 14 service personnel

+ Loss of the aircraft XV230

+ Loss of the Nimrod fleet

15 May 2017 4

Afghanistan 2 September 2006

Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) David Warrington - wwwflickrcomphotosben_salter839396254

5

The Nimrod Review October 2009

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Photo credit Martin Anderson copy Crown Copyright 2009

+ Shuttle Columbia

+ Petrobras P36

+ Buncefield

+ Teneriffe

+ Piper Alpha

+ Titanic

+ Barings Bank

+ Texas City

+Macondo

+Morecambe Bay NHS

+ Kings Cross

+Moura Mine

+ Ladbroke Grove

+ Herald of Free Enterprise

6

Organisational factors

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

7

Human and organisational factors in investigations

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF LEADERSHIP

+ Based on lsquoas designedrsquo not lsquoas isrsquo

+ Essentially a paperwork exercise

+ Design flaws dormant for decades not identified

+ Air-to-Air refuelling modification not assessed

+ Little operator input

+ Personnel involved were inexperienced with little knowledge of the aircraft

+ Not revisited following major accident to XV227 in 2004

+ Poor oversight of contractors by the MoD

+ Review conclusion An effective safety case would have prevented the disaster

9

Leadership 1 Safety cases

ldquoUnfortunately the Nimrod

Safety Case was a

lamentable job from start to

finish It was riddled with

errors It missed the key

dangers

Its production is a story of

incompetence

complacency and

cynicism

The best opportunity to

prevent the accident to

XV230 was tragically lostrdquo

(Nimrod Review p10)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Previous significant incidents

+ Incidents were treated as lsquoone-offsrsquo

+ Patterns not spotted

+ Systemic issues not identified

+ No lsquoread-acrossrsquo to other aircraft

+ No-one taking an overall view

+ Previous warnings about reducing resources

and increasing demands

10

Leadership 2 Warning signs

ldquoLearning disabilities

are tragic in children

but they are fatal in

organizationsrdquo (Robert L Sumwalt US

National Transportation

Safety Board)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A tsunami of cuts and change + 900 initiatives

+ Change assumed to be better

+ Huge organisational changes + lsquoPurplersquo tri-service organisations

+ Outsourcing

+ Sustained period of lsquoorganisational traumarsquo

11

Leadership 3 Organisational change

ldquoThe MOD suffered a

sustained period of

deep organisational

trauma between 1998

and 2006 due to the

imposition of

unending cuts and

changerdquo Nimrod Review p355

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ What is the purpose of your safety cases

+ How do you influence effective safety cases

+ Do you understand and challenge the work of contractors and consultants

+ What are the equivalent warning signs in your organisation

+ Do you help to lsquojoin up the dotsrsquo between previous incidents

+ Do you create learning opportunities

+ Are organisational changes (including cumulative impacts) creating unintended effects

12

A failure of leadership Reflections

ldquoIt is the thought word

and deed of leaders

that most influence the

attitudes behaviours

and priorities of

employeesrdquo (Nimrod Review p576)

As a leader you have a choice

You can negatively influence safety or you can positively influence safety

Which influence do you provide How When

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF CULTURE

+ 30 year operational history

+ Assumption that it was lsquosafersquo

+ The lsquoapparent safetyrsquo lulled many into a false sense of security

+ This undermined the safety case process

14

Culture 1 Nimrod is lsquosafe anywayrsquo

ldquoThe non-occurrence of system accidents or

incidents is no guarantee of a safe systemrdquo (Nimrod Review p181)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A culture of paper safety rather than real safety

+ Audits address processes not practices

+ Failed to acknowledge the gap between lsquowork

as imaginedrsquo and lsquowork as donersquo

+ Reliance on comforting PowerPoint

presentations rather than reading reports

15

Culture 2 Keeping it real

ldquoThere has been a yawning gap between the appearance and reality of

safetyrdquo (Nimrod Review p579)

ldquoThe actual content of

the Safety Case did

not matter as much as

compliance with the

rule which said one

must be produced

within a certain

timescalerdquo (Nimrod Review p312)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 3: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

3

Introduction

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY-SA 20) Airwolfhound - wwwflickrcomphotos24874528N043901870560

+ Nimrod XV230 suffered a catastrophic mid-air fire shortly after air-to-air refuelling on a routine mission

+ Aviation fuel and an ignition source

+ Crew had no access to the fire no fire suppression system + Loss of 14 service personnel

+ Loss of the aircraft XV230

+ Loss of the Nimrod fleet

15 May 2017 4

Afghanistan 2 September 2006

Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) David Warrington - wwwflickrcomphotosben_salter839396254

5

The Nimrod Review October 2009

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Photo credit Martin Anderson copy Crown Copyright 2009

+ Shuttle Columbia

+ Petrobras P36

+ Buncefield

+ Teneriffe

+ Piper Alpha

+ Titanic

+ Barings Bank

+ Texas City

+Macondo

+Morecambe Bay NHS

+ Kings Cross

+Moura Mine

+ Ladbroke Grove

+ Herald of Free Enterprise

6

Organisational factors

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

7

Human and organisational factors in investigations

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF LEADERSHIP

+ Based on lsquoas designedrsquo not lsquoas isrsquo

+ Essentially a paperwork exercise

+ Design flaws dormant for decades not identified

+ Air-to-Air refuelling modification not assessed

+ Little operator input

+ Personnel involved were inexperienced with little knowledge of the aircraft

+ Not revisited following major accident to XV227 in 2004

+ Poor oversight of contractors by the MoD

+ Review conclusion An effective safety case would have prevented the disaster

9

Leadership 1 Safety cases

ldquoUnfortunately the Nimrod

Safety Case was a

lamentable job from start to

finish It was riddled with

errors It missed the key

dangers

Its production is a story of

incompetence

complacency and

cynicism

The best opportunity to

prevent the accident to

XV230 was tragically lostrdquo

(Nimrod Review p10)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Previous significant incidents

+ Incidents were treated as lsquoone-offsrsquo

+ Patterns not spotted

+ Systemic issues not identified

+ No lsquoread-acrossrsquo to other aircraft

+ No-one taking an overall view

+ Previous warnings about reducing resources

and increasing demands

10

Leadership 2 Warning signs

ldquoLearning disabilities

are tragic in children

but they are fatal in

organizationsrdquo (Robert L Sumwalt US

National Transportation

Safety Board)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A tsunami of cuts and change + 900 initiatives

+ Change assumed to be better

+ Huge organisational changes + lsquoPurplersquo tri-service organisations

+ Outsourcing

+ Sustained period of lsquoorganisational traumarsquo

11

Leadership 3 Organisational change

ldquoThe MOD suffered a

sustained period of

deep organisational

trauma between 1998

and 2006 due to the

imposition of

unending cuts and

changerdquo Nimrod Review p355

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ What is the purpose of your safety cases

+ How do you influence effective safety cases

+ Do you understand and challenge the work of contractors and consultants

+ What are the equivalent warning signs in your organisation

+ Do you help to lsquojoin up the dotsrsquo between previous incidents

+ Do you create learning opportunities

+ Are organisational changes (including cumulative impacts) creating unintended effects

12

A failure of leadership Reflections

ldquoIt is the thought word

and deed of leaders

that most influence the

attitudes behaviours

and priorities of

employeesrdquo (Nimrod Review p576)

As a leader you have a choice

You can negatively influence safety or you can positively influence safety

Which influence do you provide How When

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF CULTURE

+ 30 year operational history

+ Assumption that it was lsquosafersquo

+ The lsquoapparent safetyrsquo lulled many into a false sense of security

+ This undermined the safety case process

14

Culture 1 Nimrod is lsquosafe anywayrsquo

ldquoThe non-occurrence of system accidents or

incidents is no guarantee of a safe systemrdquo (Nimrod Review p181)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A culture of paper safety rather than real safety

+ Audits address processes not practices

+ Failed to acknowledge the gap between lsquowork

as imaginedrsquo and lsquowork as donersquo

+ Reliance on comforting PowerPoint

presentations rather than reading reports

15

Culture 2 Keeping it real

ldquoThere has been a yawning gap between the appearance and reality of

safetyrdquo (Nimrod Review p579)

ldquoThe actual content of

the Safety Case did

not matter as much as

compliance with the

rule which said one

must be produced

within a certain

timescalerdquo (Nimrod Review p312)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 4: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ Nimrod XV230 suffered a catastrophic mid-air fire shortly after air-to-air refuelling on a routine mission

+ Aviation fuel and an ignition source

+ Crew had no access to the fire no fire suppression system + Loss of 14 service personnel

+ Loss of the aircraft XV230

+ Loss of the Nimrod fleet

15 May 2017 4

Afghanistan 2 September 2006

Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) David Warrington - wwwflickrcomphotosben_salter839396254

5

The Nimrod Review October 2009

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Photo credit Martin Anderson copy Crown Copyright 2009

+ Shuttle Columbia

+ Petrobras P36

+ Buncefield

+ Teneriffe

+ Piper Alpha

+ Titanic

+ Barings Bank

+ Texas City

+Macondo

+Morecambe Bay NHS

+ Kings Cross

+Moura Mine

+ Ladbroke Grove

+ Herald of Free Enterprise

6

Organisational factors

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

7

Human and organisational factors in investigations

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF LEADERSHIP

+ Based on lsquoas designedrsquo not lsquoas isrsquo

+ Essentially a paperwork exercise

+ Design flaws dormant for decades not identified

+ Air-to-Air refuelling modification not assessed

+ Little operator input

+ Personnel involved were inexperienced with little knowledge of the aircraft

+ Not revisited following major accident to XV227 in 2004

+ Poor oversight of contractors by the MoD

+ Review conclusion An effective safety case would have prevented the disaster

9

Leadership 1 Safety cases

ldquoUnfortunately the Nimrod

Safety Case was a

lamentable job from start to

finish It was riddled with

errors It missed the key

dangers

Its production is a story of

incompetence

complacency and

cynicism

The best opportunity to

prevent the accident to

XV230 was tragically lostrdquo

(Nimrod Review p10)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Previous significant incidents

+ Incidents were treated as lsquoone-offsrsquo

+ Patterns not spotted

+ Systemic issues not identified

+ No lsquoread-acrossrsquo to other aircraft

+ No-one taking an overall view

+ Previous warnings about reducing resources

and increasing demands

10

Leadership 2 Warning signs

ldquoLearning disabilities

are tragic in children

but they are fatal in

organizationsrdquo (Robert L Sumwalt US

National Transportation

Safety Board)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A tsunami of cuts and change + 900 initiatives

+ Change assumed to be better

+ Huge organisational changes + lsquoPurplersquo tri-service organisations

+ Outsourcing

+ Sustained period of lsquoorganisational traumarsquo

11

Leadership 3 Organisational change

ldquoThe MOD suffered a

sustained period of

deep organisational

trauma between 1998

and 2006 due to the

imposition of

unending cuts and

changerdquo Nimrod Review p355

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ What is the purpose of your safety cases

+ How do you influence effective safety cases

+ Do you understand and challenge the work of contractors and consultants

+ What are the equivalent warning signs in your organisation

+ Do you help to lsquojoin up the dotsrsquo between previous incidents

+ Do you create learning opportunities

+ Are organisational changes (including cumulative impacts) creating unintended effects

12

A failure of leadership Reflections

ldquoIt is the thought word

and deed of leaders

that most influence the

attitudes behaviours

and priorities of

employeesrdquo (Nimrod Review p576)

As a leader you have a choice

You can negatively influence safety or you can positively influence safety

Which influence do you provide How When

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF CULTURE

+ 30 year operational history

+ Assumption that it was lsquosafersquo

+ The lsquoapparent safetyrsquo lulled many into a false sense of security

+ This undermined the safety case process

14

Culture 1 Nimrod is lsquosafe anywayrsquo

ldquoThe non-occurrence of system accidents or

incidents is no guarantee of a safe systemrdquo (Nimrod Review p181)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A culture of paper safety rather than real safety

+ Audits address processes not practices

+ Failed to acknowledge the gap between lsquowork

as imaginedrsquo and lsquowork as donersquo

+ Reliance on comforting PowerPoint

presentations rather than reading reports

15

Culture 2 Keeping it real

ldquoThere has been a yawning gap between the appearance and reality of

safetyrdquo (Nimrod Review p579)

ldquoThe actual content of

the Safety Case did

not matter as much as

compliance with the

rule which said one

must be produced

within a certain

timescalerdquo (Nimrod Review p312)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 5: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

5

The Nimrod Review October 2009

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Photo credit Martin Anderson copy Crown Copyright 2009

+ Shuttle Columbia

+ Petrobras P36

+ Buncefield

+ Teneriffe

+ Piper Alpha

+ Titanic

+ Barings Bank

+ Texas City

+Macondo

+Morecambe Bay NHS

+ Kings Cross

+Moura Mine

+ Ladbroke Grove

+ Herald of Free Enterprise

6

Organisational factors

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

7

Human and organisational factors in investigations

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF LEADERSHIP

+ Based on lsquoas designedrsquo not lsquoas isrsquo

+ Essentially a paperwork exercise

+ Design flaws dormant for decades not identified

+ Air-to-Air refuelling modification not assessed

+ Little operator input

+ Personnel involved were inexperienced with little knowledge of the aircraft

+ Not revisited following major accident to XV227 in 2004

+ Poor oversight of contractors by the MoD

+ Review conclusion An effective safety case would have prevented the disaster

9

Leadership 1 Safety cases

ldquoUnfortunately the Nimrod

Safety Case was a

lamentable job from start to

finish It was riddled with

errors It missed the key

dangers

Its production is a story of

incompetence

complacency and

cynicism

The best opportunity to

prevent the accident to

XV230 was tragically lostrdquo

(Nimrod Review p10)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Previous significant incidents

+ Incidents were treated as lsquoone-offsrsquo

+ Patterns not spotted

+ Systemic issues not identified

+ No lsquoread-acrossrsquo to other aircraft

+ No-one taking an overall view

+ Previous warnings about reducing resources

and increasing demands

10

Leadership 2 Warning signs

ldquoLearning disabilities

are tragic in children

but they are fatal in

organizationsrdquo (Robert L Sumwalt US

National Transportation

Safety Board)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A tsunami of cuts and change + 900 initiatives

+ Change assumed to be better

+ Huge organisational changes + lsquoPurplersquo tri-service organisations

+ Outsourcing

+ Sustained period of lsquoorganisational traumarsquo

11

Leadership 3 Organisational change

ldquoThe MOD suffered a

sustained period of

deep organisational

trauma between 1998

and 2006 due to the

imposition of

unending cuts and

changerdquo Nimrod Review p355

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ What is the purpose of your safety cases

+ How do you influence effective safety cases

+ Do you understand and challenge the work of contractors and consultants

+ What are the equivalent warning signs in your organisation

+ Do you help to lsquojoin up the dotsrsquo between previous incidents

+ Do you create learning opportunities

+ Are organisational changes (including cumulative impacts) creating unintended effects

12

A failure of leadership Reflections

ldquoIt is the thought word

and deed of leaders

that most influence the

attitudes behaviours

and priorities of

employeesrdquo (Nimrod Review p576)

As a leader you have a choice

You can negatively influence safety or you can positively influence safety

Which influence do you provide How When

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF CULTURE

+ 30 year operational history

+ Assumption that it was lsquosafersquo

+ The lsquoapparent safetyrsquo lulled many into a false sense of security

+ This undermined the safety case process

14

Culture 1 Nimrod is lsquosafe anywayrsquo

ldquoThe non-occurrence of system accidents or

incidents is no guarantee of a safe systemrdquo (Nimrod Review p181)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A culture of paper safety rather than real safety

+ Audits address processes not practices

+ Failed to acknowledge the gap between lsquowork

as imaginedrsquo and lsquowork as donersquo

+ Reliance on comforting PowerPoint

presentations rather than reading reports

15

Culture 2 Keeping it real

ldquoThere has been a yawning gap between the appearance and reality of

safetyrdquo (Nimrod Review p579)

ldquoThe actual content of

the Safety Case did

not matter as much as

compliance with the

rule which said one

must be produced

within a certain

timescalerdquo (Nimrod Review p312)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 6: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ Shuttle Columbia

+ Petrobras P36

+ Buncefield

+ Teneriffe

+ Piper Alpha

+ Titanic

+ Barings Bank

+ Texas City

+Macondo

+Morecambe Bay NHS

+ Kings Cross

+Moura Mine

+ Ladbroke Grove

+ Herald of Free Enterprise

6

Organisational factors

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

7

Human and organisational factors in investigations

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF LEADERSHIP

+ Based on lsquoas designedrsquo not lsquoas isrsquo

+ Essentially a paperwork exercise

+ Design flaws dormant for decades not identified

+ Air-to-Air refuelling modification not assessed

+ Little operator input

+ Personnel involved were inexperienced with little knowledge of the aircraft

+ Not revisited following major accident to XV227 in 2004

+ Poor oversight of contractors by the MoD

+ Review conclusion An effective safety case would have prevented the disaster

9

Leadership 1 Safety cases

ldquoUnfortunately the Nimrod

Safety Case was a

lamentable job from start to

finish It was riddled with

errors It missed the key

dangers

Its production is a story of

incompetence

complacency and

cynicism

The best opportunity to

prevent the accident to

XV230 was tragically lostrdquo

(Nimrod Review p10)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Previous significant incidents

+ Incidents were treated as lsquoone-offsrsquo

+ Patterns not spotted

+ Systemic issues not identified

+ No lsquoread-acrossrsquo to other aircraft

+ No-one taking an overall view

+ Previous warnings about reducing resources

and increasing demands

10

Leadership 2 Warning signs

ldquoLearning disabilities

are tragic in children

but they are fatal in

organizationsrdquo (Robert L Sumwalt US

National Transportation

Safety Board)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A tsunami of cuts and change + 900 initiatives

+ Change assumed to be better

+ Huge organisational changes + lsquoPurplersquo tri-service organisations

+ Outsourcing

+ Sustained period of lsquoorganisational traumarsquo

11

Leadership 3 Organisational change

ldquoThe MOD suffered a

sustained period of

deep organisational

trauma between 1998

and 2006 due to the

imposition of

unending cuts and

changerdquo Nimrod Review p355

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ What is the purpose of your safety cases

+ How do you influence effective safety cases

+ Do you understand and challenge the work of contractors and consultants

+ What are the equivalent warning signs in your organisation

+ Do you help to lsquojoin up the dotsrsquo between previous incidents

+ Do you create learning opportunities

+ Are organisational changes (including cumulative impacts) creating unintended effects

12

A failure of leadership Reflections

ldquoIt is the thought word

and deed of leaders

that most influence the

attitudes behaviours

and priorities of

employeesrdquo (Nimrod Review p576)

As a leader you have a choice

You can negatively influence safety or you can positively influence safety

Which influence do you provide How When

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF CULTURE

+ 30 year operational history

+ Assumption that it was lsquosafersquo

+ The lsquoapparent safetyrsquo lulled many into a false sense of security

+ This undermined the safety case process

14

Culture 1 Nimrod is lsquosafe anywayrsquo

ldquoThe non-occurrence of system accidents or

incidents is no guarantee of a safe systemrdquo (Nimrod Review p181)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A culture of paper safety rather than real safety

+ Audits address processes not practices

+ Failed to acknowledge the gap between lsquowork

as imaginedrsquo and lsquowork as donersquo

+ Reliance on comforting PowerPoint

presentations rather than reading reports

15

Culture 2 Keeping it real

ldquoThere has been a yawning gap between the appearance and reality of

safetyrdquo (Nimrod Review p579)

ldquoThe actual content of

the Safety Case did

not matter as much as

compliance with the

rule which said one

must be produced

within a certain

timescalerdquo (Nimrod Review p312)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 7: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

7

Human and organisational factors in investigations

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF LEADERSHIP

+ Based on lsquoas designedrsquo not lsquoas isrsquo

+ Essentially a paperwork exercise

+ Design flaws dormant for decades not identified

+ Air-to-Air refuelling modification not assessed

+ Little operator input

+ Personnel involved were inexperienced with little knowledge of the aircraft

+ Not revisited following major accident to XV227 in 2004

+ Poor oversight of contractors by the MoD

+ Review conclusion An effective safety case would have prevented the disaster

9

Leadership 1 Safety cases

ldquoUnfortunately the Nimrod

Safety Case was a

lamentable job from start to

finish It was riddled with

errors It missed the key

dangers

Its production is a story of

incompetence

complacency and

cynicism

The best opportunity to

prevent the accident to

XV230 was tragically lostrdquo

(Nimrod Review p10)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Previous significant incidents

+ Incidents were treated as lsquoone-offsrsquo

+ Patterns not spotted

+ Systemic issues not identified

+ No lsquoread-acrossrsquo to other aircraft

+ No-one taking an overall view

+ Previous warnings about reducing resources

and increasing demands

10

Leadership 2 Warning signs

ldquoLearning disabilities

are tragic in children

but they are fatal in

organizationsrdquo (Robert L Sumwalt US

National Transportation

Safety Board)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A tsunami of cuts and change + 900 initiatives

+ Change assumed to be better

+ Huge organisational changes + lsquoPurplersquo tri-service organisations

+ Outsourcing

+ Sustained period of lsquoorganisational traumarsquo

11

Leadership 3 Organisational change

ldquoThe MOD suffered a

sustained period of

deep organisational

trauma between 1998

and 2006 due to the

imposition of

unending cuts and

changerdquo Nimrod Review p355

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ What is the purpose of your safety cases

+ How do you influence effective safety cases

+ Do you understand and challenge the work of contractors and consultants

+ What are the equivalent warning signs in your organisation

+ Do you help to lsquojoin up the dotsrsquo between previous incidents

+ Do you create learning opportunities

+ Are organisational changes (including cumulative impacts) creating unintended effects

12

A failure of leadership Reflections

ldquoIt is the thought word

and deed of leaders

that most influence the

attitudes behaviours

and priorities of

employeesrdquo (Nimrod Review p576)

As a leader you have a choice

You can negatively influence safety or you can positively influence safety

Which influence do you provide How When

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF CULTURE

+ 30 year operational history

+ Assumption that it was lsquosafersquo

+ The lsquoapparent safetyrsquo lulled many into a false sense of security

+ This undermined the safety case process

14

Culture 1 Nimrod is lsquosafe anywayrsquo

ldquoThe non-occurrence of system accidents or

incidents is no guarantee of a safe systemrdquo (Nimrod Review p181)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A culture of paper safety rather than real safety

+ Audits address processes not practices

+ Failed to acknowledge the gap between lsquowork

as imaginedrsquo and lsquowork as donersquo

+ Reliance on comforting PowerPoint

presentations rather than reading reports

15

Culture 2 Keeping it real

ldquoThere has been a yawning gap between the appearance and reality of

safetyrdquo (Nimrod Review p579)

ldquoThe actual content of

the Safety Case did

not matter as much as

compliance with the

rule which said one

must be produced

within a certain

timescalerdquo (Nimrod Review p312)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 8: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

A FAILURE OF LEADERSHIP

+ Based on lsquoas designedrsquo not lsquoas isrsquo

+ Essentially a paperwork exercise

+ Design flaws dormant for decades not identified

+ Air-to-Air refuelling modification not assessed

+ Little operator input

+ Personnel involved were inexperienced with little knowledge of the aircraft

+ Not revisited following major accident to XV227 in 2004

+ Poor oversight of contractors by the MoD

+ Review conclusion An effective safety case would have prevented the disaster

9

Leadership 1 Safety cases

ldquoUnfortunately the Nimrod

Safety Case was a

lamentable job from start to

finish It was riddled with

errors It missed the key

dangers

Its production is a story of

incompetence

complacency and

cynicism

The best opportunity to

prevent the accident to

XV230 was tragically lostrdquo

(Nimrod Review p10)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Previous significant incidents

+ Incidents were treated as lsquoone-offsrsquo

+ Patterns not spotted

+ Systemic issues not identified

+ No lsquoread-acrossrsquo to other aircraft

+ No-one taking an overall view

+ Previous warnings about reducing resources

and increasing demands

10

Leadership 2 Warning signs

ldquoLearning disabilities

are tragic in children

but they are fatal in

organizationsrdquo (Robert L Sumwalt US

National Transportation

Safety Board)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A tsunami of cuts and change + 900 initiatives

+ Change assumed to be better

+ Huge organisational changes + lsquoPurplersquo tri-service organisations

+ Outsourcing

+ Sustained period of lsquoorganisational traumarsquo

11

Leadership 3 Organisational change

ldquoThe MOD suffered a

sustained period of

deep organisational

trauma between 1998

and 2006 due to the

imposition of

unending cuts and

changerdquo Nimrod Review p355

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ What is the purpose of your safety cases

+ How do you influence effective safety cases

+ Do you understand and challenge the work of contractors and consultants

+ What are the equivalent warning signs in your organisation

+ Do you help to lsquojoin up the dotsrsquo between previous incidents

+ Do you create learning opportunities

+ Are organisational changes (including cumulative impacts) creating unintended effects

12

A failure of leadership Reflections

ldquoIt is the thought word

and deed of leaders

that most influence the

attitudes behaviours

and priorities of

employeesrdquo (Nimrod Review p576)

As a leader you have a choice

You can negatively influence safety or you can positively influence safety

Which influence do you provide How When

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF CULTURE

+ 30 year operational history

+ Assumption that it was lsquosafersquo

+ The lsquoapparent safetyrsquo lulled many into a false sense of security

+ This undermined the safety case process

14

Culture 1 Nimrod is lsquosafe anywayrsquo

ldquoThe non-occurrence of system accidents or

incidents is no guarantee of a safe systemrdquo (Nimrod Review p181)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A culture of paper safety rather than real safety

+ Audits address processes not practices

+ Failed to acknowledge the gap between lsquowork

as imaginedrsquo and lsquowork as donersquo

+ Reliance on comforting PowerPoint

presentations rather than reading reports

15

Culture 2 Keeping it real

ldquoThere has been a yawning gap between the appearance and reality of

safetyrdquo (Nimrod Review p579)

ldquoThe actual content of

the Safety Case did

not matter as much as

compliance with the

rule which said one

must be produced

within a certain

timescalerdquo (Nimrod Review p312)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 9: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ Based on lsquoas designedrsquo not lsquoas isrsquo

+ Essentially a paperwork exercise

+ Design flaws dormant for decades not identified

+ Air-to-Air refuelling modification not assessed

+ Little operator input

+ Personnel involved were inexperienced with little knowledge of the aircraft

+ Not revisited following major accident to XV227 in 2004

+ Poor oversight of contractors by the MoD

+ Review conclusion An effective safety case would have prevented the disaster

9

Leadership 1 Safety cases

ldquoUnfortunately the Nimrod

Safety Case was a

lamentable job from start to

finish It was riddled with

errors It missed the key

dangers

Its production is a story of

incompetence

complacency and

cynicism

The best opportunity to

prevent the accident to

XV230 was tragically lostrdquo

(Nimrod Review p10)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Previous significant incidents

+ Incidents were treated as lsquoone-offsrsquo

+ Patterns not spotted

+ Systemic issues not identified

+ No lsquoread-acrossrsquo to other aircraft

+ No-one taking an overall view

+ Previous warnings about reducing resources

and increasing demands

10

Leadership 2 Warning signs

ldquoLearning disabilities

are tragic in children

but they are fatal in

organizationsrdquo (Robert L Sumwalt US

National Transportation

Safety Board)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A tsunami of cuts and change + 900 initiatives

+ Change assumed to be better

+ Huge organisational changes + lsquoPurplersquo tri-service organisations

+ Outsourcing

+ Sustained period of lsquoorganisational traumarsquo

11

Leadership 3 Organisational change

ldquoThe MOD suffered a

sustained period of

deep organisational

trauma between 1998

and 2006 due to the

imposition of

unending cuts and

changerdquo Nimrod Review p355

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ What is the purpose of your safety cases

+ How do you influence effective safety cases

+ Do you understand and challenge the work of contractors and consultants

+ What are the equivalent warning signs in your organisation

+ Do you help to lsquojoin up the dotsrsquo between previous incidents

+ Do you create learning opportunities

+ Are organisational changes (including cumulative impacts) creating unintended effects

12

A failure of leadership Reflections

ldquoIt is the thought word

and deed of leaders

that most influence the

attitudes behaviours

and priorities of

employeesrdquo (Nimrod Review p576)

As a leader you have a choice

You can negatively influence safety or you can positively influence safety

Which influence do you provide How When

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF CULTURE

+ 30 year operational history

+ Assumption that it was lsquosafersquo

+ The lsquoapparent safetyrsquo lulled many into a false sense of security

+ This undermined the safety case process

14

Culture 1 Nimrod is lsquosafe anywayrsquo

ldquoThe non-occurrence of system accidents or

incidents is no guarantee of a safe systemrdquo (Nimrod Review p181)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A culture of paper safety rather than real safety

+ Audits address processes not practices

+ Failed to acknowledge the gap between lsquowork

as imaginedrsquo and lsquowork as donersquo

+ Reliance on comforting PowerPoint

presentations rather than reading reports

15

Culture 2 Keeping it real

ldquoThere has been a yawning gap between the appearance and reality of

safetyrdquo (Nimrod Review p579)

ldquoThe actual content of

the Safety Case did

not matter as much as

compliance with the

rule which said one

must be produced

within a certain

timescalerdquo (Nimrod Review p312)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 10: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ Previous significant incidents

+ Incidents were treated as lsquoone-offsrsquo

+ Patterns not spotted

+ Systemic issues not identified

+ No lsquoread-acrossrsquo to other aircraft

+ No-one taking an overall view

+ Previous warnings about reducing resources

and increasing demands

10

Leadership 2 Warning signs

ldquoLearning disabilities

are tragic in children

but they are fatal in

organizationsrdquo (Robert L Sumwalt US

National Transportation

Safety Board)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A tsunami of cuts and change + 900 initiatives

+ Change assumed to be better

+ Huge organisational changes + lsquoPurplersquo tri-service organisations

+ Outsourcing

+ Sustained period of lsquoorganisational traumarsquo

11

Leadership 3 Organisational change

ldquoThe MOD suffered a

sustained period of

deep organisational

trauma between 1998

and 2006 due to the

imposition of

unending cuts and

changerdquo Nimrod Review p355

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ What is the purpose of your safety cases

+ How do you influence effective safety cases

+ Do you understand and challenge the work of contractors and consultants

+ What are the equivalent warning signs in your organisation

+ Do you help to lsquojoin up the dotsrsquo between previous incidents

+ Do you create learning opportunities

+ Are organisational changes (including cumulative impacts) creating unintended effects

12

A failure of leadership Reflections

ldquoIt is the thought word

and deed of leaders

that most influence the

attitudes behaviours

and priorities of

employeesrdquo (Nimrod Review p576)

As a leader you have a choice

You can negatively influence safety or you can positively influence safety

Which influence do you provide How When

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF CULTURE

+ 30 year operational history

+ Assumption that it was lsquosafersquo

+ The lsquoapparent safetyrsquo lulled many into a false sense of security

+ This undermined the safety case process

14

Culture 1 Nimrod is lsquosafe anywayrsquo

ldquoThe non-occurrence of system accidents or

incidents is no guarantee of a safe systemrdquo (Nimrod Review p181)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A culture of paper safety rather than real safety

+ Audits address processes not practices

+ Failed to acknowledge the gap between lsquowork

as imaginedrsquo and lsquowork as donersquo

+ Reliance on comforting PowerPoint

presentations rather than reading reports

15

Culture 2 Keeping it real

ldquoThere has been a yawning gap between the appearance and reality of

safetyrdquo (Nimrod Review p579)

ldquoThe actual content of

the Safety Case did

not matter as much as

compliance with the

rule which said one

must be produced

within a certain

timescalerdquo (Nimrod Review p312)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 11: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ A tsunami of cuts and change + 900 initiatives

+ Change assumed to be better

+ Huge organisational changes + lsquoPurplersquo tri-service organisations

+ Outsourcing

+ Sustained period of lsquoorganisational traumarsquo

11

Leadership 3 Organisational change

ldquoThe MOD suffered a

sustained period of

deep organisational

trauma between 1998

and 2006 due to the

imposition of

unending cuts and

changerdquo Nimrod Review p355

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ What is the purpose of your safety cases

+ How do you influence effective safety cases

+ Do you understand and challenge the work of contractors and consultants

+ What are the equivalent warning signs in your organisation

+ Do you help to lsquojoin up the dotsrsquo between previous incidents

+ Do you create learning opportunities

+ Are organisational changes (including cumulative impacts) creating unintended effects

12

A failure of leadership Reflections

ldquoIt is the thought word

and deed of leaders

that most influence the

attitudes behaviours

and priorities of

employeesrdquo (Nimrod Review p576)

As a leader you have a choice

You can negatively influence safety or you can positively influence safety

Which influence do you provide How When

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF CULTURE

+ 30 year operational history

+ Assumption that it was lsquosafersquo

+ The lsquoapparent safetyrsquo lulled many into a false sense of security

+ This undermined the safety case process

14

Culture 1 Nimrod is lsquosafe anywayrsquo

ldquoThe non-occurrence of system accidents or

incidents is no guarantee of a safe systemrdquo (Nimrod Review p181)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A culture of paper safety rather than real safety

+ Audits address processes not practices

+ Failed to acknowledge the gap between lsquowork

as imaginedrsquo and lsquowork as donersquo

+ Reliance on comforting PowerPoint

presentations rather than reading reports

15

Culture 2 Keeping it real

ldquoThere has been a yawning gap between the appearance and reality of

safetyrdquo (Nimrod Review p579)

ldquoThe actual content of

the Safety Case did

not matter as much as

compliance with the

rule which said one

must be produced

within a certain

timescalerdquo (Nimrod Review p312)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 12: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ What is the purpose of your safety cases

+ How do you influence effective safety cases

+ Do you understand and challenge the work of contractors and consultants

+ What are the equivalent warning signs in your organisation

+ Do you help to lsquojoin up the dotsrsquo between previous incidents

+ Do you create learning opportunities

+ Are organisational changes (including cumulative impacts) creating unintended effects

12

A failure of leadership Reflections

ldquoIt is the thought word

and deed of leaders

that most influence the

attitudes behaviours

and priorities of

employeesrdquo (Nimrod Review p576)

As a leader you have a choice

You can negatively influence safety or you can positively influence safety

Which influence do you provide How When

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF CULTURE

+ 30 year operational history

+ Assumption that it was lsquosafersquo

+ The lsquoapparent safetyrsquo lulled many into a false sense of security

+ This undermined the safety case process

14

Culture 1 Nimrod is lsquosafe anywayrsquo

ldquoThe non-occurrence of system accidents or

incidents is no guarantee of a safe systemrdquo (Nimrod Review p181)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A culture of paper safety rather than real safety

+ Audits address processes not practices

+ Failed to acknowledge the gap between lsquowork

as imaginedrsquo and lsquowork as donersquo

+ Reliance on comforting PowerPoint

presentations rather than reading reports

15

Culture 2 Keeping it real

ldquoThere has been a yawning gap between the appearance and reality of

safetyrdquo (Nimrod Review p579)

ldquoThe actual content of

the Safety Case did

not matter as much as

compliance with the

rule which said one

must be produced

within a certain

timescalerdquo (Nimrod Review p312)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 13: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

A FAILURE OF CULTURE

+ 30 year operational history

+ Assumption that it was lsquosafersquo

+ The lsquoapparent safetyrsquo lulled many into a false sense of security

+ This undermined the safety case process

14

Culture 1 Nimrod is lsquosafe anywayrsquo

ldquoThe non-occurrence of system accidents or

incidents is no guarantee of a safe systemrdquo (Nimrod Review p181)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A culture of paper safety rather than real safety

+ Audits address processes not practices

+ Failed to acknowledge the gap between lsquowork

as imaginedrsquo and lsquowork as donersquo

+ Reliance on comforting PowerPoint

presentations rather than reading reports

15

Culture 2 Keeping it real

ldquoThere has been a yawning gap between the appearance and reality of

safetyrdquo (Nimrod Review p579)

ldquoThe actual content of

the Safety Case did

not matter as much as

compliance with the

rule which said one

must be produced

within a certain

timescalerdquo (Nimrod Review p312)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 14: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ 30 year operational history

+ Assumption that it was lsquosafersquo

+ The lsquoapparent safetyrsquo lulled many into a false sense of security

+ This undermined the safety case process

14

Culture 1 Nimrod is lsquosafe anywayrsquo

ldquoThe non-occurrence of system accidents or

incidents is no guarantee of a safe systemrdquo (Nimrod Review p181)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ A culture of paper safety rather than real safety

+ Audits address processes not practices

+ Failed to acknowledge the gap between lsquowork

as imaginedrsquo and lsquowork as donersquo

+ Reliance on comforting PowerPoint

presentations rather than reading reports

15

Culture 2 Keeping it real

ldquoThere has been a yawning gap between the appearance and reality of

safetyrdquo (Nimrod Review p579)

ldquoThe actual content of

the Safety Case did

not matter as much as

compliance with the

rule which said one

must be produced

within a certain

timescalerdquo (Nimrod Review p312)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 15: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ A culture of paper safety rather than real safety

+ Audits address processes not practices

+ Failed to acknowledge the gap between lsquowork

as imaginedrsquo and lsquowork as donersquo

+ Reliance on comforting PowerPoint

presentations rather than reading reports

15

Culture 2 Keeping it real

ldquoThere has been a yawning gap between the appearance and reality of

safetyrdquo (Nimrod Review p579)

ldquoThe actual content of

the Safety Case did

not matter as much as

compliance with the

rule which said one

must be produced

within a certain

timescalerdquo (Nimrod Review p312)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 16: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ ldquoCapacity to waste money is legendaryrdquo

+ Delays and extortion + Over-run 80 on average

+ Over-spend 40 on average

+ Creates bow-waves of deferred financial problems

+ Convoluted procurement chain + Non-conforming parts on aircraft

+ Procurement had no specialist aviation knowledge

+ Nimrod involvement in Afghanistan and Iraq due to unsuitable drones purchased

16

Culture 3 Procurement

But for the delays in the

Nimrod MRA4 replacement

programme XV230 would

probably have no longer

have been flying in

September 2006 because

it would have reached its

Out-of-Service Date and

already been scrapped or

stripped for conversion (Nimrod Review p12)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 17: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ Do you think that all is well because of historical experience

+ What assumptions are you making in key decisions ndash are these still valid

+ How do you know that what you think is happening IS actually happening

+ How do you encourage the reporting of bad news errors or near-misses

+ Do you actively create the culture or just let it happen

+ When things are going well do you ask more questions (rather than fewer)

17

A failure of culture Reflections

ldquoNASAʼs blind spot is it

believes it has a

strong safety culturerdquo (Columbia Accident

Investigation Board

CAIB 2003 p203)

ldquohellip it is worth pointing

out that if you are

convinced that your

organisation has a

good safety culture

you are almost

certainly mistakenrdquo (James Reason 1997)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 18: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

A FAILURE OF PRIORITIES

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 19: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ Financial pressures + lsquocutsrsquo lsquosavingsrsquo lsquoefficienciesrsquo lsquostrategic

targetsrsquo lsquoreduction in output costsrsquo lsquoleaningrsquo

+ Led to + a move from safety and airworthiness to

business and financial targets

+ a dilution of the airworthiness regime

+ Delivering changes distracted from safety and airworthiness issues

19

Priorities 1 Shift from airworthiness

ldquoThere was no doubt

that the culture at the

time had switched In

the days of Sir Colin

Terry you had to be on

top of airworthiness

By 2004 you had to be

on top of your budget

if you wanted to get

aheadrdquo (Nimrod Review p355)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 20: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ Increased operational demands

(Iraq and Afghanistan)

+ Assumptions behind changes not

revisited as demands increased

+ Insufficient checks and balances

+ Less oversight of key activities

such as the safety case

20

Priorities 2 Demands

ldquoUK Armed Forces

were required to play a

major role in two major

conflicts Iraq and

Afghanistan at the

same time as coping

with major change and

re-structuring and

delivering major

financial savingsrdquo (Nimrod Review p365)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 21: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ Need more care resources and

vigilance

+ Serial delays in Nimrod replacement

+ Out-of-service date extended

+ Uncertainty

+ Lack of investment in Nimrod

+ Planning and sourcing spares

+ Parts-swapping between aircraft

21

Priorities 3 Aging aircraft

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

(CC BY 20) Karen - wwwflickrcomphotoskaren_od4555772012

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 22: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ How might budget cuts challenges strategic targets initiatives etc have unintended consequences

+What are your key messages to your teams and to the business

+What targets do you set

+ How can project or production pressures live comfortably with safety

+ Are you managing aging facilities

+ Do you accept conditions or behaviours that you wouldnrsquot have a few years ago

22

A failure of priorities Reflections

ldquoIf reliability and safety are

preached as lsquoorganizational

bumper stickersrsquo but

leaders constantly

emphasize keeping on

schedule and saving

money workers will soon

realize what is deemed

important and change

accordingly Such was the

case with shuttle programrdquo (Brigadier General

Duane W Deal USAF 2004

Nimrod Review p491)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 23: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ ldquoThe fundamental failure was a failure of Leadership As preceding Chapters

have shown lack of Leadership manifested itself in relation to the way in which

the Nimrod Safety Case was handled in the way in which warning signs and

trends were not spotted and in relation to inexorable weakening of the

Airworthiness system and pervading Safety Culture generallyrdquo

(Nimrod Review p 491)

23

Summary

+ ldquoMany of these lessons and truths may be unwelcome uncomfortable and

painful but they are all the more important and valuable for being so It is better

that the hard lessons are learned now and not following some future catastrophic

accidentrdquo

(Nimrod Review p 580)

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 24: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

+ Not my problem

+ Irsquom too busy

+ It wouldnrsquot happen here

+MoD BAE amp QinetiQ are

bad companies

+Wersquore top quartile

+Question and challenge

+ Leadership

+ Culture

+ Priorities

+ Embed learnings

24

You now have a choice Itrsquos up to you

Leaders create the time and space for good people to do great things

or

15 May 2017 Martin Anderson ndash Reflections on Nimrod xv230

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau

Page 25: NIMROD XV230: REFLECTIONS ON LEADERSHIP, CULTURE AND … · 2017-05-20 · Leadership 2: Warning signs “Learning disabilities are tragic in children, but they are fatal in organizations”

Woodside Energy Ltd

240 St Georges

Terrace

Perth WA 6000

GPO Box D188

Perth WA 6840

Australia

T +61 8 9348 4000

F +61 8 9214 2777

E companyinfowoodsidecomau

woodsidecomau