2.1 MORE THAN A SIMPLE ACCIDENT
On the evening of 12 June 1996, during a routine training exercise near Townsville in Queensland, two Australian Army Black Hawk helicopters collided and crashed to the ground in a massive fireball. 18 soldiers died and 12 were injured. Many similar exercises had been practised, why did this one go horribly wrong? This case is examined in detail in this chapter.
The reports of the boards of inquiry and coronial inquests studied in this and other chapters each identify a series of factors combining at a single culminating point, with catastrophic results. The na ї ve might argue this was chance. Chance certainly played a critical part, but only in the terminal stages. First, the circumstances had to be created by man; only then could chance play its final tragic role. These precursor circumstances could have, and should have, been recognised and managed. If this had been done, the outcomes may have been quite different. As suggested in Chapter 1, there is an interesting paradox here. It is highly likely that, by managing the precursor circumstances, those in positions of responsibility would have been able to avert tragedy. But, what had been successfully averted would have gone unnoticed because it never would have occurred. There could be no public acknowledgment that management action had been effective. Often, the consequence of this paradox is an attitude of complacency, or denial, that there are problems. Evidence that there may be problems is easily dismissed or conveniently adjusted. This is explained further at Chapter 3.
Complex and difficult ‘wicked’ problems are treated like a Pandora’s Box. Many fear opening the Box, living in trepidation that they may not be able to comprehend what they will find. It is much easier to ignore the Box. So they go through life blissfully ignorant of how systemic influences play themselves out unless tragedy strikes. Effective management strategies can only be built on a clear understanding of what influences are at play and how they interact. Our focus, therefore, should be on identifying when and how influences are likely to combine to produce undesirable outcomes. Then, we can set about routinely managing to prevent the forces combining in an unfavourable way. This is what risk management is all about.
The Black Hawk helicopter crash case study is used to demonstrate when, where and how we might apply management effort to mitigate risks routinely, thereby stopping them from growing. Alternatively, we can apply our efforts to changing the structure of the problem that particular risks become less of a threat to our purposeful human activities. The Board of Inquiry Report is reviewed using systems thinking and concept-mapping techniques.