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Iam an experienced and senior aviation engineer with a background in safety and risk management, airworthiness, project and change management. I retired from the military in 2019 and since then have been fortunate enough to gain a perspective on air and

space-based project management from both the viewpoint as a senior consultant and as an artefact shepherd for a major aircraft developer and producer. In this intentionally provocative piece, I want to convey my thoughts on how frequently risk management is badly executed and why. I intend this piece to be provoking, so no apologies for being a bit vague with facts or examples – this is a food for thought piece, not a factual article.

In this multifaceted, short article I will provide opinion on five aspects of why risk management is frequently poorly managed. The causal elements I will cover are:• Training• Situational Awareness• Failure to understand or follow the consequences of mitigation/controlling action• Seeing Bow-Ties, and similar techniques as a once only artefact• Risk and Safety Management by PowerPoint.

Buckle up and see if you recognise any of these traits in the projects you have worked on in the past, or are currently working on.

TrainingI have participated in hazard workshops where the main protagonists have often used outdated approaches or have allowed poorly defined risks, hazards and controls to permeate through the exercise of documenting and managing risk. These central characters are often sitting on past glories or qualifications over which they have not enriched or updated through broadened experience or continuous training. This is an easy trap to get into and there is a reason why professional bodies now ask to see Continuous Professional Development (CPD) records. Often professional individuals reject the need for training, based upon the assumption that repeating the same thing one did years ago will add little value and/or waste time – I have been guilty of this myself. Three important judgements are missing from this style/attitude. Firstly is the fact that change is constant – new ideas, initiatives and methods often come about in safety and risk management. Secondly, it can be easy to forget that what individuals contribute in debate within a training course is often some of the most valuable parts; new insights and ideas flow from shared experiences and lessons learned. Finally, sometimes similar training but delivered

under a different context can help broaden and develop skills – if your employer is only offering one route of access to safety and risk training, make a case for doing similar training but in a different setting; safety and risk training comes in many guises.

Situational Awareness – Loss ofSituational awareness (SA) is • The perception of the elements in the environment within a volume of time and space• The comprehension of their meaning and• The projection of their status in the near future.

A loss of situational awareness in risk management often leads to fatal consequences and is often cited in accident reports. Loss of situational awareness often happens early in an accident chain, is a slow burner and can have fatal consequences. The UK Health & Safety Executive provides a good example in their seven steps tool-sheets on this subject:

On 27th August 2006, Comair flight 5191 took off from the wrong runway. It was early morning and still dark outside as the captain (highly experienced and trained) was taxiing the aeroplane to the runway. Instead of taking the right runway, he took a wrong turn, which led the plane on to a runway that was too short for take-off. During take-off the cockpit is a designated quiet area to allow for

The demise of successful risk managementHere, a senior aviation manager looks at how poor risk assessment methods can have fatal consequences and what must be done to make our lives safer

J A M I E S AY E R C E N G M B A S I I R S M R P P

Retired Royal Navy Commander, Jamie Sayer CEng MBA SIIRSM RPP, is now Senior Principal Systems Engineer & UAS Expert at QinetiQ.

KNOWLEDGEEssential risk intelligence from

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concentration. On this occasion, the captain and co-pilot were chatting, affecting everyone’s performance. Allowing this talk meant that the situational awareness of the captain and co-pilot was reduced and they failed to spot that they were on the wrong runway. Their perception of reality was different to the actual reality. Despite the co-pilot pointing out that there were no lights on the runway it was another 15 seconds before the captain realised what was happening, by which time it was too late. They failed to stop work despite recognising a hazard (there were no lights even though it was dark). If they had stopped work and brought their situational awareness in line with actual reality, 49 people would still be alive today.

I have personally been involved in conversations surrounding a critical aircraft failure mode exhibiting frequent similar occurrences. During

investigations and conversations, I observed that there was a tendency to jump to the nearest controlling mitigator without fully considering all of the options to bring the situation to As Low As Reasonable Practicable (ALARP) in risk terms. Also the failure rate was assessed using the easiest method – failure numbers versus established flying hours during

use. This type of approach can miss important aspects. For example, say that there was possibly an error in how the reliability and assumed life of a component had been calculated. The following simple failure distribution diagram (below), borrowed from Kumar and Sarkar’s paper on Improvement Of Life Time and Reliability of Batteries, helps explain the point.

If a component producer has based the life of a component of the ‘wear-out’ cycle and set a life of say 5,000 hours, but in the harsh reality of the operating environment the ‘wear-out’ curve has broadened or entirely shifted to the left, then as the component grows in age, the failure rate is likely to increase. Therefore if you are only sampling ‘young’ components to calculate your failure rate, you are missing the ‘ageing’ concern – you have lost situational awareness in the three aspects of the earlier provided definition.

Failure to understand or follow the consequences of mitigation/controlling actionThis failure mechanism is closely linked to the previous cause of loss of SA and the two combined can lead to deep disappointment. I will avoid

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the easy reach for COVID 19 examples, as the topic tends to be extremely controversial, but the consequences of lockdown are far reaching and receive relatively little airtime. At the time of writing this, COVID 19 is no longer the biggest cause of death in the UK, but many lockdown restrictions remain in place. There are approximately 800,000 fewer people on payroll since the pandemic started and 400,000 additional people under the age of 35 years are now unemployed. The Office for Budget Responsibility, the Government’s independent economics forecaster, expects unemployment to peak at about 7.5% later this year – representing 2.6 million people1. Public sector net borrowing (excluding public sector banks, PSNB ex) in the FYE March 2021 is estimated to have been £303.1 billion, £246.1 billion more than in the FYE March 2020 and the highest nominal public sector borrowing in any financial year since records began in the FYE March 19472.

In my opinion, there is a lack of analysis/transparency on what restrictions are actually proven to reduce transmission and hence in the longer term more harm could be caused by ineffective lockdown restrictions than the virus itself.

The two final steps of good risk management are to treat the risk and then monitor. In my experience, it is this last step that often does not get the requisite attention. One should always attempt to fully understand and try to predict the consequences of a mitigating/controlling action. I am reminded of that disquieting moment in The Cruel Sea when Ericson takes the terrible, but necessary, decision to run down the survivors of a torpedoed ship in order to go after the U-boat.

Difficult decisions often have to be made for good risk management and sometimes mitigating actions don’t get executed because of the costs of those actions. Programmes and projects that are failing or heading into risky waters have a tendency to continue on that course because leaders fail to have the courage to change direction or radically alter the programme due to the consequences of sunk costs, and spent effort.

Seeing Bow-Ties and similar techniques as a once only artefactRisk management tools are there to be used. Situations are constantly evolving and changing. Risk management tools therefore should routinely be revisited, particularly when something changes the status quo or new information is brought to bear. However, quite often these tools are seen as a poster child or showpiece for an auditor and not used as an everyday tool. People often get unnecessarily worried about configuration control of these tools, when they really should worry more about

whether they are getting used for the intent they were created for. If you recognise any of these practices in your organisation, you would be wise to speak up about them.

Risk and Safety Management by PowerPointWhen asked to produce a safety strategy, I once provided a comprehensive but short report. I was surprised by the reaction to this when I was told that senior management wouldn’t read it and I should change it to a PowerPoint presentation.

It appears that some people have not learned the hard lessons from the Haddon-Cave report The Nimrod Review on ‘The danger of PowerPoint’.

Presentations quite rightly have a valuable role to play in the management of risks, but should always be backed up by written reports which can then be referred to, particularly if the architect of a PowerPoint presentation has moved on.

As the Haddon-Cave report put it:

“The use of PowerPoint in the MOD is endemic. PowerPoint can, however, be dangerous,

mesmerising, and lead to sloppy (or nil) thinking.”

Inappropriate replacement of genuine risk reports, strategies, plans, methods and deployment activity by PowerPoint should always be challenged. The excuses that senior management do not have time to read these things is, in my mind, no longer acceptable.

SummaryAs stated at the outset of this short piece, this was intended to be a thought-provoking article brought about by years of observation on poor examples of risk management. If you recognise any of these practices, perhaps this will provide the prompt that something should be done about them. Good risk management comes from a combination of practice, training and attitudes and the right levels of cultural buy-in. Therefore, it starts at the very top, where sometimes a nudge might be needed.

1 The Guardian, UK unemployment reaches four-year high in Covid-19 lockdown, 21 Jan 2021.2 ONS, UK Public Sector Finances, March 2021.