With This Many Recommendations, Where Do We Start?

F35B on board a Royal Navy Aircraft Carrier. Image courtesy of the Royal Navy, MOD.

In November 2021, an F-35B Lightning sat on the deck of HMS Queen Elizabeth waiting to launch during operations in the Mediterranean. The pilot completed his checks, the aircraft was cleared for departure and max power was applied. Seconds later, it became apparent that max power wasn't being delivered. The aircraft struggled to accelerate, staggered into the air before immediately beginning to sink, and within moments the pilot had ejected safely while the aircraft landed in the sea next to the carrier. A fighter aircraft worth around £100 million had been lost. The 'cause' of the lack of thrust was an engine intake blank that hadn't been removed pre-flight.

Like so many accidents we've looked at, the final report tells a far more interesting story than the headlines ever did. The intake blank was certainly the final piece of the puzzle, but it wasn't really the cause in the way most people understand the word. The report describes, in great detail, a complex operational environment involving fatigue, engineering pressures, multiple organisations, assumptions, workarounds and a series of opportunities for the system to detect the problem before the aircraft left the deck. The detail of the accident itself is very interesting, but a more intriguing aspect of the report is that it has 46 recommendations.

Forty-six.

One has to ask, If there are forty-six of them, where do we start? What do we prioritise?

Good recommendations change the system

I genuinely like that this report recognises issues that many organisations struggle with: People will become tired; Information won't always flow as well as we'd like; Different teams will naturally develop different ways of completing the same task; Rather than pretending those realities don't exist, some of the recommendations attempt to strengthen the system around them.

Take fatigue as an example. The report recommends implementing procedures to actively manage fatigue during operations and exercises in order to maintain air safety. I like that recommendation because it accepts fatigue as something that has to be managed rather than eliminated. Nobody working in aviation, healthcare, mining, shipping or emergency services expects people to remain perfectly rested all the time. Demanding operations in safety critical industries (or any other industry for that matter) don't work like that. Good organisations acknowledge the problem and ask what processes, routines or leadership behaviours can reduce its impact.

The recommendation to improve safety reporting across the global F-35 community follows the same philosophy. Instead of relying on each operator learning expensive lessons independently, it asks to share information so emerging trends can be recognised much earlier. This is systems thinking in its purest form. And it's awesome!

Likewise, standardising the fitment of intake blanks removes unnecessary variation from a task which clearly depended too heavily on local practices and individual interpretation.

None of those recommendations ask people simply to be more careful. They change the environment in which people work, making success more likely and failure less so. That's what a good recommendation should do: leave somebody with clear ownership, a measurable change and a reasonable expectation that the system will perform better next time.

Activity isn't the same as accountability

At the same time, some of the other recommendations left me less convinced. I don't disagree with what they're trying to achieve. Quite the opposite in fact. The intentions are entirely sensible and honourable. My concern is that some of them are written in a way that makes accountability quite difficult to achieve which, in terms of the bigger picture, makes me ask what they really achieve at all.

One recommendation, for example, calls for engineering orders and work instructions to be demonstrated as "robust and effective". Another recommends resourcing the engineering workforce sufficiently to ensure maintenance can be carried out safely during embarked operations. These recommendations bring up a simple question:

What would success actually look like?

How would somebody know when those recommendations had been completed? What evidence would demonstrate that engineering instructions were now sufficiently "robust"? How many engineers would constitute "enough"? Enough for routine operations? Enough for surge activity? Enough to account for leave, sickness and unexpected defects? Every engineering manager I've ever met would welcome additional resources. Unfortunately, resources are finite and, like it or not, leadership is largely about making decisions within those constraints, especially in the military which, more and more, has to work with constrained manpower resources.

A way of thinking about this is investigations unintentionally drifting towards activity rather than accountability. It's relatively easy to produce recommendations that sound reassuring. It's much harder to produce recommendations that genuinely change operational performance and give somebody a clear standard against which they can hold themselves accountable.

One approach creates paperwork. The other changes behaviour.

A Just Culture Doesn't End With The Investigation

This report explicitly stated that its purpose was not to attribute blame but to understand what happened and reduce the likelihood of recurrence. That's what a Just Culture should be trying to achieve and I genuinely think the report did a great job of that. Too often we think of Just Culture simply as deciding whether somebody should or shouldn't be blamed after an accident. In reality, that's only a small part of it.

A mature Just Culture empowers people to improve the system. It gives leaders ownership of meaningful changes rather than simply telling them to "do better". The recommendations on fatigue, standardisation and information sharing all achieve that because they identify something tangible that can be improved. More importantly, they recognise that the next accident probably won't look exactly like the last one which is a lesson many organisations miss.

If we focus solely on preventing intake blanks being left inside engines, we may well stop that particular accident happening again. The next accident, however, is unlikely to involve an intake blank. It will involve something else that nobody has thought about yet. Good recommendations therefore shouldn't solve yesterday's problem (well they should but that's arguably quite easy). What they should do is strengthen the system's ability to deal with tomorrow's uncertainty.

Recommendations Should Prepare You For Your Next Difficult Day

One of the themes running through these recent blogs has been the difference between fixing the trigger and strengthening the system. The MV Dali wasn't really about a loose electrical wire. The tug collision on the Mississippi wasn't really about a mobile phone. The Maldives tragedy wasn't really about divers breaking the rules. Each of those accidents challenged us to look beyond the obvious explanation and ask how the wider system either prevented, or failed to prevent, the outcome.

This report fits the same pattern. As I said in the second paragraph, the intake blank was the trigger. The recommendations are where useful learning begins.

Wading through all forty-six of them had me pondering whether organisations sometimes confuse being comprehensive with being effective. Producing a long list of actions creates the impression that something meaningful has happened, yet anyone who has worked in a large organisation knows what usually follows. Actions are allocated, spreadsheets are updated, meetings are held and, eventually, every recommendation is marked as complete. Does completion mean improvement?

Perhaps we should ask which recommendations will make the biggest difference on our next difficult day? This is a challenge. It forces leaders to think about operational performance rather than administrative compliance. It asks where finite time, money and effort will produce the greatest reduction in risk. It also accepts a few things that every leader already knows, even if they don't always say it out loud.

No organisation has unlimited resources.

Every organisation makes trade-offs.

Safety isn't an organisation's number 1 priority (this blog talks more about this).

The purpose of an investigation isn't to eliminate every risk. It can't. The purpose is to strengthen the system where it matters most, so that when uncertainty inevitably returns, the people at the sharp end have a better chance of succeeding than they did last time.

That's what good recommendations look like. They don't explain away yesterday's accident.

They improve tomorrow's performance.

Full disclosure, this blog was drafted by me and then tweaked with AI to make it more readable. AI does a much better job of this than I can. 

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Mike Mason and Sam Gladman are the co-founders of On Target, a leadership and team development company that brings elite fighter pilot expertise into the corporate world. With decades of combined experience in high-performance aviation, they specialise in translating critical skills such as communication, decision-making, and teamwork into practical tools for business. Through immersive training and cutting-edge simulation, Mike and Sam help teams build trust, improve performance, and thrive under pressure—just like the best flight crews in the world.

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