Decision Making / 3 / 3.2 / 3.2.5

3.2.5 What We Can Draw From The Completed Maps

We must be careful not to overlook the fact that the complete picture, the maps of the Coroner’s Report as presented here could only be known after the Coroner had completed his deliberations of the evidence as captured in some 10,000 pages of transcript and evidence presented to the Court. Figure 3-10 graphically depicts the complexity of the problem. This, as mentioned earlier, is a high-level aggregation of the 33 individual maps produced, in turn, from the 657-page Coroner’s Inquest Report. That Report is the result of the intellectual effort and expert consideration by the Coroner.

The Coroner was clear and objective in his application of the ‘reasonable person’ test. This test is a good and robust one. It means a strong measure of objectivity can be created instead of opinion and speculation. For our purposes the test is interpreted as follows. Firstly, what is it that a reasonable person could have reasonably known in the circumstances? Secondly, what is it that with the aid of systems thinking, could a reasonable person have identified? This test suggests that the systemic structures that exist at a point in time are reasonably identifiable, should we choose to look for them. In retrospect, situation awareness, nervousness about the evolving problem situation should have been developing early in the piece. This is when effective management effort could have been, or should have been, applied. But it was not.

Similarly, in the Black Hawk case, at worst there was denial and inaction, at best there was poor risk management. The most influential, or influenced, active node in place many months before the accident was … failure to understand and manage risks associated with implosion. This is Concept No 19 in Figures 3-10 and 3-11. Winding back the clock in the Black Hawk case produces similar findings: much of the systemic structure of the problems was set in place a long time before the crash. Failure to understand, to learn and, hence, to manage risks was also dominant in that case. See Concept No 4 in Figure 2-5. This suggests the key to avoiding systemic problems lies in systems thinking and situation awareness, recognising the developing patterns, noting that the patterns and warning signs do not suddenly appear. In the year before the Black Hawk crash, Channel 9’s Current Affair ran a story on the appalling state of unserviceability of Army’s Black Hawk fleet of helicopters. They interviewed Lieutenant General John Sanderson, the Chief of the Australian Defence Force (CDF). Sanderson admitted that, despite taking delivery of Black Hawks in 1988, Army had insufficient spares to keep more than about one quarter of the fleet of 20 Black Hawk helicopters operationally available at any one time. He said that the ADF was ‘finding out’ about spares [maintenance and training] as it went along. Clearly this was not good enough.

Despite the remoteness from evolving problem situations that both Sanderson in the Black Hawk case and Carnell in the Canberra Hospital Implosion case have claimed, C. West Churchman (1961; 1971) would argue strongly that those in positions of power have moral and ethical responsibilities that simply cannot be ignored. This suggests that managers at all levels have a duty of care to be more diligent and more effective in finding out about problem situations within their domains of action.