Challenge the accepted


December 9th, 2017 by Robert Morris


In Part 1, we outlined the case for why we need to innovate just to stay in the same place, let alone improve. We also noted that despite a clear intent at the highest levels of the ADF, we lack a coherent joint strategy, a cultural impetus and comprehensive organisational system to generate ideas and deploy them on the battlefield.

In part 3, we will put forward our vision for a future innovation ecosystem. But before we get to that, we are going to take a look at a recent example of a significant, successful and well documented organisational transformation in the ADF.

“Today is Yesterday’s Pupil” – Benjamin Franklin, Poor Richard’s Almanack

The example we will examine is the 1990s reforms to ADF aviation safety management, where the ADF underwent a significant organisational transformation which led to a 16-fold reduction in fatal accident rates. This transformation has left the ADF with a comprehensive aviation safety management system, a leadership that takes organisational responsibility for aviation safety, and a culture that has safe practice built into its DNA. There is little doubt that these changes have averted many destroyed aircraft and lost lives in the ADF.

While the problems of safety management and innovation management are significantly different, there are many parallels to be drawn between them. This article will highlight three key lessons to inform the required reform to the way we manage innovation in the ADF:
1) A systematic organisation-wide approach
2) A genuine command commitment, and
3) Cultural change.

The Bad Old Days

In the period 1970-1991, a ‘normal’ year for ADF aviation was one in which there were multiple fatal aircraft crashes. In fact, over this period there was an average of 2.6 fatal aircraft crashes each year. Every aviation accident that results in death or injury is an individual tragedy for all involved, their friends, their family and the ADF. But each accident is not an individual event to be considered in isolation.

As indicated in the graph below, this is exactly how the ADF treated aviation accidents and incidents before the 1990s reforms.

Image from Defence Aviation Air Force Safety

This lack of understanding of the organisational causes of accidents led to investigations that were content to identify the actions or inactions of individuals – human errors, carelessness and procedural violations – and attribute blame for the accident on these proximate causes. The result was recommendations like tighter supervision, more training or disciplinary action. The effect of this ‘operator error focus’ was that while each accident saw individual deficiencies remediated, there was no overall improvement to the safety of the organisation – in fact fatal accident rates trended upwards from the mid-1970s to the early 1990s.

Failure originates in top-level decisions and proceeds via … deficiencies in the organisational systems or processes
– James Reason, A Systems Approach to Organisational Error

Before 1991 there was no lasting unified approach to the evaluation of technical and operational risks for military aircraft in Australia. The reforms to aviation safety introduced James Reason’s Organisational Accident Model into the aviation safety management. The Reason model goes beyond identifying the proximate causes of accidents, and instead finds the ultimate causes, in the form of latent failures that exist at the workplace or organisational level.

The lesson?

An organisational problem requires an organisational solution.

The organisational solution enacted by the ADF was the Defence Aviation Safety Management System. This is a systematic approach to managing safety, including the necessary organisational structures, policies, procedures and plans.

The ASMS posits that the foundation element of the system is genuine command commitment, upon this element all others are built.

“Without a commander’s wholehearted commitment, any safety management system will be ineffective. The commander must accept the requirement for a robust ASMS and ensure all subordinates are aware of the command commitment to ASMS.

Commanders must continually demonstrate their commitment to aviation safety, as this will directly influence the attitudes, beliefs, values and behaviours of subordinates, and their commitment to aviation safety.”
– ADF Aviation Safety Management Manual

As we explained in Part 1, without cultural change, then strategy is likely to fail.

A culture can be thought of as ‘the way we do things around here’. According to Professor Patrick Hudson’s ladder of organisational safety culture, organisations should strive for a ‘generative safety culture’, or one in which safe behaviour is fully integrated into everything the organisation does.

Hudson’s Ladder of Safety Culture

Image courtesy of

Without the ingrained organisational culture, systems break down and become futile. The 1994 introduction of a comprehensive set of technical regulations had dramatically reduced maintenance error as a cause of aviation accidents. Then in 2005, a Sea King helicopter tragically crashed on Nias Island killing nine people. The immediate cause of the accident was found to be through a maintenance error.

How could this happen?

A pathological safety culture existed within the responsible Navy maintenance organisation, which led to routine violations of regulations. All the systems, regulations and even command commitment did nothing because of an aberrant culture.

Lessons for Innovation

Our failure to become the innovative force that we need to be cannot be attributed to a lack of creativity or ‘innovativeness’ of individuals, but instead a failure to create an organisational environment conducive to innovation.

To date, the ADF has lacked a systematic, joint approach to innovation strategy. Leadership – while supportive – has not been relentlessly committed to the cause. And while there are encouraging pockets of culture, it hasn’t yet permeated the organisation and become built into our DNA.

Where good ideas fail to be deployed as battlefield innovations, the responsibility rests ultimately with leaders, whose responsibility it is to set the innovation framework and conditions that lead to success, communicated through an aligning narrative. In Part 1 we raised the concept of innovation friction, the aspects of the organisation that overtly or inadvertently restrict the flow of innovation. A comprehensive innovation system creates the environment for innovation to flourish, while the wholehearted commitment of leadership will allow the reduction of obstacles to reduce friction and increase the flow of innovation.

As show in the Sea King example, systems alone will fail without the right culture. We propose that our military needs to undergo a similar cultural transformation, where a genetically embedded innovation culture sees every individual approach every activity with an approach of ‘how could this be done better’.

It’s also worth noting that—perhaps counterintuitively—in a change effort, culture comes last, not first. As John P. Kotter, author of the seminal work on change management, Leading Change, wrote:

“Change sticks when it becomes ‘the way we do things around here,’ when it seeps into the bloodstream of the corporate body. Until new behaviours are rooted in social norms and shared values, they are subject to degradation as soon as the pressure for change is removed”


We need to learn from both our mistakes and successes of the past. The case of safety reform in the ADF is largely one of success, and should serve to provide us lessons for future organisational transformations. To summarise, the main lessons that we have taken forward are:

1. An organisational level problem needs an organisation solution. Grand gestures and platitudes will not make us the innovative force we need to be. A Defence innovation system needs to be built to provide the environment for innovation to flourish.

2. Without leader’s wholehearted commitment, any innovation system will be ineffective. Leaders must continually demonstrate their commitment to innovation, as this will directly influence the attitudes, beliefs, values, habits and behaviours of subordinates.

3. Cultural change is the force that anchors a wider organisational change in place. The ADF needs a culture of innovation and a ‘H-hour sense of urgency’ embedded in its DNA. Innovation occurs from the bottom up, without a shared vision that innovation is the way we do things in our organisation, then all other initiatives will likely fall flat.

In Part 3 we will deliver our vision for an ADF innovation ecosystem, what that will look like, and how we can get there.

About the author

Rob Morris is a RAEME officer at the Air Warfare Centre, and holds a Bachelor of Engineering (Aerospace) and a Masters of Project Management. Rob has worked in aviation safety and studied masters level organisational change management and strategic management. Rob was a co-winner of DEF Aus 2016 with his pitch on augmented reality, and has been a presenter this year at the Institute for Regional Security ‘Next’ forum and at the Army Futures Day.

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