In my fifth post on the Nimrod incident, as we approach the 10th anniversary of this terrible event, I discuss organisational change. Such change may be inevitable, but does it have to lead to disaster?
The Nimrod Review, an independent investigation into the catastrophic fire on a Nimrod reconnaissance aircraft in 2006, highlighted organisational change as a key issue. The Review stated that:
“The MOD suffered a sustained period of deep organisational trauma between 1998 and 2006 due to the imposition of unending cuts and change, which led to a dilution of its safety and airworthiness regime, and culture and distraction from airworthiness as the top priority” (Nimrod Review, 2009, p.355).
The Nimrod Review outlines in detail the many organisational changes that had an impact on safety and airworthiness; so many in fact that they are described as a ‘tsunami’ of cuts and change (for example, over 900 cost-reducing initiatives in the Defence Logistics Organisation). The ‘organisational trauma’ referred to in the quote above is reported to have stemmed from a Strategic Defence Review in 1998, which was more of a continuous process rather than a discrete change.
These constant and significant organisational changes led to conditions such as high workloads, pressures and a reduced focus on safety; which in turn led to the Nimrod XV230 disaster. Poorly-managed organisational change was a cause in many other major incidents, such as the fire at Hickson & Welch, NASA Shuttles Challenger and Columbia, BP Texas City and Esso Longford. It’s also cited as a cause in various major healthcare investigations, such as Morecambe Bay and Mid Staffs – for more details see my Parallels with healthcare post.
As a Specialist Inspector (Human Factors) with the UK HSE for many years, organisational change was a topic on which I frequently provided support, guidance and in some cases enforcement action. The key is that organisational change needs the same rigorous management approach as that traditionally taken to engineering or technical changes. And yet despite a large amount of freely available guidance on this topic, many companies still struggle to robustly address organisational change.
Whatever it is that defines ‘safety’ for your organisation, whether that is keeping chemicals in the pipes, keeping trains on the tracks, airplanes in the sky, or not harming patients; it is essential that any significant organisational changes are assessed for their impact on safety. This will include assessing changes to: roles and responsibilities, organisational structures, reporting relationships, staffing levels, staff location, outsourcing, use of contractors, delayering, downsizing and centralisation of functions. My experience is that assessments of significant changes are often sub-standard.
There are two aspects of any change that need to be assessed and managed:
- risks resulting from the change outcomes – such as insufficient staffing levels, increased workload, conflicting priorities, loss of experience and shift in priorities;
- risks during the process of change itself – such as unclear roles, uncertainty and reduced morale. When the focus is on cost-cutting, staff may perceive that there is less focus on safety and their well-being. Staff may stop reporting near-misses and there may be less ‘questioning’.
Remember that the impacts of change can be direct or indirect – and may not be immediately apparent. For example, a reduction in supervision may gradually lead to a change in working practices, which will be passed through training and observation to the next generation of personnel. Also key is that the cumulative impact of successive changes needs to be assessed, as well as the individual changes themselves. Incremental changes can lead an organisation to slowly drift into failure.
Often, the impacts of changes may not be apparent under normal day-to-day activities, but in an upset or emergency, inadequate staffing numbers, a lack of experience or unclear roles & responsibilities can turn a minor problem into a major incident.
As a health and safety inspector, one of my first questions to a company undergoing organisational change was “How will this change improve the management of safety?”. However, this does not happen by chance, it needs to be managed.
I have two challenges for leaders who are responsible for implementing organisational changes:
- “If you failed to manage this change, what could be the safety implications?”.
- “How will you know that you got it wrong, before a major incident occurs?”.
The following quote from The Nimrod Review is worth repeating here in full, for it sums up the devastating impact that the organisational changes had on the Ministry of Defence, and how these changes led to the loss of Nimrod XV230 on 2nd September 2006:
“Change can be seriously inimical to safety and airworthiness unless properly planned, resourced and managed. It can lead to the organisational dilution of safety structures. It can lead to a diversion of resources from safety matters. It can distract attention from safety issues. It can lead to a shift in priorities. It can change the culture. In this case, it did” (Nimrod Review, 2009, p.368).
Categories: human factors