The Role of Leadership in Aviation
The Role of Leadership in Aviation
The Role of Leadership in Aviation
2478/fas-2020-0001
FATIGUE OF AIRCRAFT STRUCTURES
Volume 2020: Issue 12, pp. 1-14
ABSTRACT
Ensuring aircraft are technically safe to operate is the realm of airworthiness, literally
worthy of being in the air. This is achieved not only with technological tools and
techniques, or with just personnel and manpower, it is guided and supervised by
managers and leaders. As such, the objective of this paper is to understand the role
leadership plays in maintaining aviation safety and aircraft airworthiness. To this end,
a case study of the Hawker Sidley Nimrod XV230 accident that occurred on September
2, 2006 near Kandahar in Afghanistan, was utilized. The study concluded that leadership
is a key aspect, specifically finding that leaders are responsible for articulating
the organizations vision, strategic objective setting, and monitoring the achievement of
those objectives. It was concluded that operational airworthiness is directly dependent
on the leadership ability to provide direction, workplace culture, continued learning,
and establish risk management systems for safe and airworthy operations.
INTRODUCTION
The global aviation industry is comprised of three key segments: general aviation,
commercial aviation, and military aviation [1]. Commercial aviation plays a critical role
in the global economy by facilitating commerce, tourism, and world trade. Commercial
aviation is undertaken in a value chain where the key stakeholders are aircraft
manufacturers, aircraft maintenance organizations, airlines, airports, ground handling
agents, tour operators and in-flight catering firms [2]. In 2018, the world’s airlines
carried 4.32 billion passengers and 58 million tonnes of air cargo on their scheduled
services [3]. Safety is the principal concern of the global aviation industry [4].
Airworthiness plays a fundamental role in underpinning the industry’s objective of safe
aircraft operations.
Aircraft maintenance in particular has been identified a key issue in aviation safety,
contributing to a number of accidents and incidents in the industry [5]. In the last decade
the number of officially reported accidents that has resulted from technical issues,
referred to as a system component failure, has been around 22% [6]. Of these, most
of them are the result of issues not associated with the engine (non-powerplant, NP,
issue), around 16% of the total accidents; while approximately 6% of the total accidents
are due to issues with the engine (powerplant, PP). Combined, these technical issues
account for the most common issue in aircraft accidents (abnormal runway contact is
the next most common in 18% of cases). Ensuring these technical issues do not result
in accidents (serious injury and/or damage, or potentially even death and/or destruction)
is the purview of the many airworthiness [7]. While there is a well-known growth is air
traffic, both passengers and cargo (when there is not a global crisis), there is also
a growing number of safety occurrences. This fact is obfuscated by the industry trend
to report accidents as a “risk” relative to the amount of traffic (departure, kilometers,
passengers etc). As such, there is a need at all levels to improve safety in the aviation
industry, and leadership in technical organizations is as important as leadership in
operational organizations (such as airlines).
RESULTS
The Case
The Hawker Sidley Nimrod was Britain’s new maritime patrol aircraft and entered
service in 1969. It was a repurposing of the infamous de Havilland Comet. The Comet
is infamous as it is the aircraft associated with the development of the “black box”, or
as it is technically known, the flight data recorder. This was because there were a number
of incidents where what should had been perfectly serviceable and reasonable new
Comets aircraft were lost in flight, along with all passengers. The initial design of
the Comet had windows that were too large and square, resulting in stress concentrations
and failures in the airframes which were pressurized so the jet could fly at high altitudes.
The Comet evolved, and the issues were address, and the 4th version of this aircraft was
the basis of the Nimrod. The first Nimrod to enter service was the XV230. The Nimrod
is pictured in Figure 2.
Figure 2. The Hawker Sidley Nimrod, XV230, the aircraft lost in the case accident,
along with all crew onboard (Crown copyright, The Nimrod Review).
The following example of an aircraft accident sets the context for the present paper
and highlights the devastation associated with aircraft accidents. On 2nd September 2nd,
2006, RAF Nimrod XV230 is reported to have suffered a catastrophic mid-air fire.
The aircraft was on a routine mission in the Helmand Province in Afghanistan.
The accident led to the death of all 14 service personnel on board, becoming the biggest
source of life of British service personnel in one single incident since the Falklands
War. The fire was caused by leaking fuel ignited by an exposed hot cross-feed pipe.
These lives were lost not by enemy fire but rather a technical failure, an accident that
was waiting to happen. The Defence Aviation and Air Force Safety, together with
Hon Sir Charles Haddon-Cave QC, who lead the inquiry into the accident [17],
presented the case to the Australian Defence College in 2014 and outlined the findings
of the assessment [18].
Hon Sir Charles Haddon-Cave noted that even though catastrophic accidents have
been reported in various parts of the world, such as the Fukushima, Malaysian Airways
Flight 370, as well as Deepwater Horizon, among others, in addition to aircraft
accidents, it could be surmised that there were essentially no accidents as the principles
underlying all these incidents was the same. The presentation surmised that these
incidents and accidents were related to airworthiness. With specificity to the RAF
Nimrod XV230 case, the assessment showed that the factors that led to the accident
could be traced to what had happened for over 30 years, and these included: poor design
and modifications to the hot pipes and the fuselage, the high risk history of fuel tanks
captured in the 1970s and 1980s and the resultant normalization of the deviance,
increased operational activity of the aircraft in theatres in the 1990s and 2000s, increased
maintenance problems associated with an fleet of aging aircrafts, organizational changes
and budgetary cuts in the Ministry of Defence between 2000 and 2005, outsourcing of
the responsibility for keeping the Nimrod aircrafts safe between 2004 and 2005, and
finally the air to air refueling which caused the inevitable. Reports submitted to the RAF
noted that the aircraft had a fuel leak in 2005, and this needed to be rectified prior to
operation in Afghanistan. Additional reports also showed the operational environment
(hot on the ground, 40oC, and cold in the air, -40oC) were causing further issues with
the known fuel leak. This highlights the fact the issue was not even a surprise or mystery,
it was a latent failure, just waiting to happen. That is, the accident was caused by
organizational issues including leadership and culture, principles and professionalism,
simplicity, and safety.
In a very safe system such as modern aviation the greatest threat to safety is seen by
Dekker [24] as a drift into failure. This drift is where the practices of the workers slowly
move away from the promulgated procedures. The drift arises as workers deal with time
and production pressures [25]. When an accident does occur after work practices have
drifted from promulgated procedures and in hindsight it appears as the cause of
the accident was the lack of correct following of the procedures as causation, it is seen
by Dekker [24] as a very unsatisfactory way of explaining this why the accident happened.
The drift of practice away from promulgated procedures is incremental. Accidents in
a very safe industry such as aviation, rarely happen because of large or unorthodox
movements away from promulgated procedures [24]. Because of the incremental nature
of the drift it is difficult to notice and therefore does not attract attention. This drift is
not something that may happen but is unremitting. It may at times be only a slow drift
or at other times even give the appearance of not happening at all, and at other times
seem that the practice has become settled. At other times it may give the appearance of
being continually unsettled. However, the practise drift is never still, it is always moving
and changing [24]. In describing this practise drift within organisations Vaughan [26]
uses the language of “organisational deviance” which she takes to be “routine
nonconformity: a predictable and recurring product of all socially organised systems”
(p. 274).
Another component of airworthiness is risk evaluation. At the heart of determining
what is wrong or what could go wrong are various methods of risk management that
seek to measure the risk of occurrence of a specific incident or accident. Risk
management entails risk evaluation which encompasses identifying the event or scenario
of interest, determining the likelihood of occurrence, and establishing the possible
consequences. Continuing airworthiness risk evaluation involves routine collection of
high-quality data, establishment of incident trends, identification of flaws in the system,
and development of corrective actions in addition to continuous monitoring [20].
Clothier et al. [23] reiterate that risk should be assessed based on particular risk criteria
for different scenarios and systematic decisions made in setting controls to guide
appropriate treatment of risks over time.
From the analysis, airworthiness is not only influenced by aircraft related factors
such as design, manufacture, and maintenance but also by the management system,
hence there is a need to evaluate how organizational processes influence airworthiness.
In Australia, the responsibility of managing safety in military aviation falls under
the Defence Aviation Safety Program, which is administered by three agencies:
the Australian Defence Force, Directorate of Defence Aviation and Air Force Safety,
and Airworthiness Coordination and Policy Agency. These regulators develop and
publish operational airworthiness regulations which define the standards that aircraft
must comply with. There are two types of airworthiness. Technical airworthiness is
concerned with the design, construction, and maintenance of aircraft to approved
standards. Operational airworthiness is concerned with human performance and all
aspects of organizations which influence the operation of the aircraft within acceptance
levels of risk [27]. Figure 3 shows the typical organizational structure of an
airworthiness system, as defined by ICAO. Leadership in this complex organization is
therefore a very important element to achieve operational airworthiness, and comes
from many places, in the government and in the operator.
Purton and Kourousis [29] noted that Military Aviation Authorities (MAAs)
have established regulatory provisions that align with the principles developed by
the International Civil Aviation Organization (ICAO). MAAs are also responsible for
certification, approvals and inspection processes for the acquisition, operation, and
airworthiness of air systems. To achieve these objectives, the Military Aviation
Authorities have also adopted the four principles for a new airworthiness system
outlined in the Haddon-Cave report.
Aircraft airworthiness can be regarded as a process that involves combined efforts
of the use of technology along with efficient use of human efforts which is possible
with a team of personnel that understand the importance of ensuring reliability, safety
and efficacy for aircraft operations. Since aircraft maintenance personnel work in
supervised teams, the importance of the effective leadership skills cannot be overlooked
[30]. De Brito Neto [31] stated that with an increase in global air operations, the aviation
industry has witnessed a rise in multicultural work force which can be facilitated with
the adoption of either the transformational leadership theory or the positive leadership
theory. Mrusek [12] and Adams, Owen, Scott, and Parsons [32] emphasize on the need
for collaborative leadership which encourages communication in the work environment
as aviation maintenance management is an amalgamation of efforts of various
departments.
Aerospace leadership is defined as that attribute that is practiced by all members of
the aerospace community so as to achieve the needs of the organizations, of the aircraft
fleets, as well as all those who depend on the safety of the aerospace industry. Aerospace
leadership entails leading by example. This is achieved through applying responses
to lessons that have been learned and nurturing unselfish cooperation in the community.
Within organizations, leaders are committed to mentoring and developing stuff,
encouraging the proactive utilization of existing knowledge and experience, and adopting
a long-term approach towards driving the growth of individuals and the organization
[33].
Leaders play a central role in the development of a safety culture. A safety culture
arises from individual employee and group or organizational beliefs, values, attitudes,
competencies, and behavior regarding safety. An organization can be said to possess
a robust safety culture when communications are based on mutual trust and sharing is
deemed important for building safety measures [34]. The call for building safety culture
originated from the nuclear energy industry and the aviation industry because these
industries must learn how to manage risk consistently and systematically so as to avoid
costly accidents. To create safety culture in these industries, it has been determined that
leaders must demonstrate high levels of commitment in their decisions as well as
behaviors; they must lead the development of a systematic, rigorous, and thorough safety
framework; they must encourage trust and respect across organizational hierarchies;
they must pursue opportunities for learning multiple ways through which safety
measures can be implemented and the safety of personnel, equipment, property and
public ensured; they must demand early identification of issues affecting safety, fully
evaluate them, and promptly address them; and finally, they must strive to nurture an
environment where people feel safe to raise safety concerns without fear of
discrimination [35].
The importance of leadership in the development of organizational safety culture
was identified in Trew, Trigunarsyah, and Coffey research [36]. They surveyed seven
Australian airworthiness management programs within airlines which were concerned
with keeping aircraft in an airworthy state. Their factor analysis of the survey results
sought to describe the organizational culture within the airworthiness sphere. Assurance
was found to be he cultural trait that ensured the ongoing airworthiness of aircraft
in the respective program. Within the trait of assurance “leadership has a role in
establishing the organizational culture, practices and behaviors which optimizes
the benefits sought from the program” (p. 164).
When leaders are competent and thoughtful, they positively contribute to continuous
improvements in safety and organizational culture. This is because they have an in-
depth understanding of all the systemic flaws that exist in the system and steps that can
be taken to reduce the potential of failure, especially since the majority of failures can
be attributed to human mistakes. According to James Reason’s “Swiss Cheese Model”,
systemic flaws are the hazards and weaknesses that increase the likelihood of an incident
or accident. The identification of these latent hazards and weaknesses is the first step
towards the development of solutions necessary for preventing errors from occurring,
and more importantly, incidents and accidents that may lead to catastrophic loss of both
personnel and equipment [37].
Effective leaders understand the need to inculcate teamwork in creating a safety
culture. Such leaders deliberately adopt strategies and tactics that strengthen the safety
culture by viewing safety issues as organizational system issues and not merely blame
employees. They ensure that all employees understand operational hazards and
collectively work towards reducing the likelihood of incidents and accidents.
To successfully establish a teamwork approach towards safety, Reason identified three
main components: just culture, reporting culture, and learning culture [38].
A just culture is where personnel are encouraged and sometimes rewarded for
providing crucial information that can be used to improve safety, while ensuring that
there is a clear differentiation between human error and risky reckless behaviors.
Reporting culture is where all internal stakeholders recognize the responsibility
of reporting errors and near-misses. On the other hand, a learning culture is where there
is a willingness and competence to utilize quality data to analyze situations and reach
conclusions that inform the development and implementation of safety measures.
Data quality is also a component of airworthiness. For data to be deemed to be of high
quality, it must be accurate in the sense that it must precisely report and record a specific
attribute; it must be reliable in that it must identify and record the same event in
the same way; and finally it must be valid meaning that represent only that which is to
be recorded to be useful in decision-making. Organizations with strong safety cultures
are characterized by staff who cooperate and share knowledge on how to improve
the safety of the work environment. High perceptions of safety positively influence
the culture while low perceptions directly or indirectly underline safety outcomes.
In analyzing leadership, it is crucial to identify the people who are responsible for
providing leadership. Organizations should strive to ensure that sound leadership
behavior is cultivated at all levels of the organization. Leadership culture teaches that
leadership is the responsibility of every individual irrespective of their positions,
whether one is an aircraft engineer, a maintenance technician, a logistics officer,
a supervisor, a finance manager, or any other position in the organization [33]. While
all employees are required to demonstrate leadership attributes, other employees have
greater leadership responsibility than others. For instance, those in lower positions in
terms or organizational hierarchy depend on those in senior positions for inspiration
and motivation. Persons in senior positions should inspire respect as they mentor and
develop their subordinates. How they share the vision of an organization influences
the level of commitment subordinates will invest in pursuing the goals necessary for
achieving the grand vision. Inspired, motivated, respected, and valued employees are
more likely to use their knowledge, capabilities, and experience to drive organizational
aspirations [33].
There are various step-by-step measures that leaders can undertake to enhance
airworthiness. Leaders should support the development of systems which encourage
transparency and eliminate any form or punitive actions when it comes to reporting and
learning from incidents and accidents. The importance of understanding maintenance
errors alongside the promotion of a culture that identifies, reports and learns from
maintenance errors for improving work quality and safety cannot be ignored [39, 40].
This calls for the development of a clear and efficient organizational reporting system
that is accessible to everyone. Such a system encourages trust and accountability
while also promoting a culture where unsafe conditions are identified and reported
using appropriate channels without any fear of reprisals or punishment [39, 40].
In organizations where employees fear to report safety issues because of punishments
or reprisals, it becomes difficult to institute proactive prevention systems.
Leadership should establish risk management processes that have the ability of
recognizing risk elements and differentiating between human errors and risks that arise
from poorly designed organizational systems. In normal organizational operations,
mistakes, lapses, omissions, and errors occur. By broadly and specifically carrying out
risk or hazard identification, organizations can avoid cases where an employee is
punished or terminated for making a mistake without carrying out a full and thorough
investigation so as to understand all the sources of unsafe conditions. A transparent risk
management guideline helps to create an open, fair, and accountable safety culture.
Leaders should build trust in the organization. This is demonstrated by how leaders
interact with their subordinates, how they participate in organizational activities, and
the programs they implement to enhance airworthiness. In doing that, there should also
be a communication system with clear policies to support organizational-wide
communication of all aspects of airworthiness.
Leaders should be good coaches [41, 42]. This implies that leadership is through
example [43, 44]. By leading from the front, sharing skills, knowledge and direction
with followers becomes more effective. Leaders should be active participants in safety
briefings, planning sessions, debriefing, as well as safety rounds and walkarounds.
Additionally, leadership provides guidance in establishing the airworthiness baseline
and how to measure whether an organization is achieving airworthiness standards.
DISCUSSION
Findings
The Hawker Sidley Nimrod XV230 accident is an interesting case with a long
history, with many lessons to learn. Previous work has highlighted technical and general
safety lesson [45]. Looking inductively at the data presented, it is clear that a link
between success in terms of airworthiness and the leadership responsible for that
airworthiness and safety. The intricate case study shown here, is a classic example of
what in systems thinking is called a “wicked problem”. That is, the complex interactions
between all the elements in the system result in unintended complex problems. That is,
the aircraft alone was not at fault, neither were the many engineering teams responsible
for each and every modification to the Nimrod over its 30+ year service life, similarly
the environment was not solely responsible, nor were the individual leaders. However,
in a far more complex “game” of who sank the boat, the components of the system
interact in unexpected negative ways to produce a failure. A great example of this, is
the fact that leaders saw the great safety record of the Nimrod as an indicator that it was
capable of more and would continue to maintain its high level of safety. The key feature
in the Nimrod case study, is that leadership does have an obligation and the ability to
provide an overview to factor in all aspects. As shown in the case study, documents
were provided to show that there were issues that needed to be considered by leaders
and factored into any operational decisions made.
CONCLUSION
The objective of this paper was to address the role leadership and culture play in
maintaining aviation safety and aircraft airworthiness. The study concluded that
leadership is an important aspect of any organizational entity. It was also found that
leaders are responsible for articulating the vision of an organization, setting the strategic
objectives, establishing activities that must be implemented to achieve stated objectives,
and evaluating the level of achievement of objectives over time. Leaders also lead
organizational personnel. Leaders lead by example. They inspire respect, trust, and
commitment to organizational vision and mission, while also inspiring and motivating
subordinates to give their best. The study has concluded that operational airworthiness
is dependent on the ability of organizational leadership to provide effective direction,
stimulate teamwork and organizational learning, and establish sound risk management
framework necessary for not only isolating the hazards and risks as well as mitigate
against all aspects that may have a direct or an indirect effect on airworthiness.
The study also finds the importance of incorporating all involved personnel in aircraft
maintenance in leadership training programs so that the role of leadership is realized,
accepted, and executed at all levels of personnel equally.
REFERENCES