3.7 FAILURE TO LEARN—FAR TOO COMMON

In the Black Hawk helicopter case, declining morale may have been attributed to a single obvious cause by those involved, at 5^th Aviation Regiment, or by Army’s personnel managers. This is not clear from the Board of Inquiry’s report. If declining morale and other warning signs had been recognised and their implications better understood, as suggested by the concept-mapping analysis in Chapter 2, it is very likely this might have triggered corrective action and contributed to reducing the opportunity for tragedy to occur.

This concept mapping and systems thinking analytical approach advocated here allows us to identify those concepts critical under ‘normal’ circumstances or might become critical. Critical concepts, in the case described in this chapter, were:

Black Hawk helicopter crash - failure to inform judgement of those responsible for designing combined arms training and associated safety [and support?], see Figure 2-5 and 2-6.
Royal Canberra Hospital implosion case - failure to understand, failure to learn, and failure to manage risks. This is not numbered in Figures 3-8 and 3-11, but is numbered as Concept No 19 in Figures 3-10 and 3-11. The common thread might well express to tie these cases together is failure to understand the complexity being faced, failure to learn and, hence, failure to manage risks.