"Gross Negligence" or Something Else?...

The wreckage of ZD576. Picture: PA

On the evening of 2 June 1994, an RAF Chinook HC2 helicopter took off from RAF Aldergrove in Northern Ireland carrying twenty-nine people. On board were the four crew and twenty-five senior intelligence personnel travelling to a conference in Inverness. Less than half an hour later the aircraft struck the Mull of Kintyre in poor weather, killing everyone on board. It remains one of the worst peacetime accidents in RAF history and, more than thirty years later, is still discussed for reasons that have surprisingly little to do with the crash itself.

The official explanation appeared straightforward. Investigators found no conclusive evidence of a catastrophic technical failure and concluded that the aircraft had been flown into high ground while in cloud. The two experienced pilots, Flight Lieutenants Jonathan Tapper and Rick Cook, were found to have been grossly negligent. Tragically, they had died in the accident, yet the official record left little room for doubt: the accident had been caused by pilot error and, as far as the RAF was concerned, the case was effectively closed.

That wasn't the end of the matter.

A parliamentary inquiry in 2001 concluded that the finding of gross negligence was unjustified and recommended it be reconsidered. A decade later, following an independent review, the pilots were formally cleared of negligence and it was accepted that the RAF had incorrectly declared the aircraft compliant with airworthiness regulations. to fly.

We all want someone to blame

When people die or are seriously injured, we need to find someone to blame. We need closure. It makes us feel better. That's perfectly normal. Human beings prefer certainty to uncertainty.

We instinctively want to find mistakes. We want to identify flawed decisions. We want to be able to point at the people who made those mistakes and decisions. We feel pressure, individually and as teams or organisations, to find certainty. Saying 'We don't know' feels like a failure.

We don't do any of this because we're malicious. We do it because we want to feel in control. If we can identify someone to blame, it gives us a sense of control. If we can identify the mistakes or the rules that were broken, we can fairly easily convince ourselves that it won't happen again.

This is comforting to us psychologically but reality isn't that simple and, other than giving us short-term relief, we aren't fixing problems in the long term.

The standard was deliberately high

The RAF rules at the time were such that aircrew involved in accidents could only be found grossly negligent if there was absolutely no doubt whatsoever. By definition this sets a very high bar and this is a good thing. Dead people can't explain themselves. Accident data recorders (black boxes) can tell us a great deal about 'what' happened. They are much less effective at telling us 'why' it made sense to the people involved at the time. This is a crucial distinction because accidents are rarely explained by actions alone; they're explained by the context in which those actions occurred.. Recognising uncertainty is a useful leadership lesson. Applying certainty where there isn't any is far worse than accepting uncertainty where it exists.

As mentioned in the opening paragraph, this isn't what happened to Tapper and Cook. For reasons that have never really been articulated clearly (to me at least), despite the findings of the board of inquiry, two senior RAF officers overruled them and declared the two pilots guilty of gross negligence.

In 1997, the RAF, in recognition of the fact that deceased personnel wouldn't be able to defend themselves, changed their rules further such that Boards of Inquiry were unable to attribute negligence or blame to deceased crews. Personally, I support this change. If you've read our other blogs, you'll know I believe people don't turn up to work intending to have a bad day or crash. People almost always behave in ways that make sense within the system they're working in. Blaming individuals doesn't help.

This isn't really an aviation story

While I've used a well known aviation accident to bring this blog to life, there is more to it than aviation.

Every modern high risk organisation investigates accidents and incidents. These organisations will reach conclusions. As part of this evolution, we have to decide, 'When do we know enough?'

Investigations don't begin with a complete picture. They begin with fragments. A witness statement here. A damaged component there. A few pieces of recorded data. Rarely do those pieces fit together neatly, yet we expect investigators to assemble them into a coherent story and, ultimately, provide certainty. That's a far more difficult task than many people appreciate.

We need to consider that investigators are human too. They are subject to bias, especially confirmation bias. When they have an idea of what happened, they are naturally more inclined to believe the pieces that support their belief and discount the pieces that don't. This isn't incompetence or bad intent. It is part of what makes humans human - wanting to make things certain.

Keep asking questions. Keep challenging your own assumptions.

Have we confused confidence with evidence?

Are there more questions we need to ask? And answer?

Are we solving the right problems?

Final thoughts

Every leader has to make decisions before they have all the information. That is normal and unavoidable. What I want to get across is that the challenge isn't necessarily about making decisions under uncertainty.

The challenge relates to recognising when your levels of certainty have gone beyond the evidence you have to support it.

Jonathan Tapper and Rick Cook never had the opportunity to explain the decisions they made that day.

None of this means we should avoid making difficult decisions or holding people accountable. It simply reminds us that accountability deserves evidence, not assumptions. The Mull of Kintyre case shows how easily confidence can outgrow the facts, and how long the consequences of that can last. The next time you're convinced you know the whole story, pause for a moment and ask yourself one more question.

What evidence would change my mind?

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Mike Mason (the one on the left) joined the RAF a few years after the accident. Like many young pilots, he knew the names before he knew the facts. The case was still discussed in crew rooms because it challenged something every aircrew member hoped would never happen. If the worst occurred, would the investigation be fair? Would the evidence speak for itself? Or could people reach conclusions that later turned out to be wrong?

If you'd like to learn more about how On Target can help your team, contact Mike and Sam (the one on the right) at info@ontargetteaming.com.