To make the system work, the RAF tries to create what it calls a ‘just culture’. When someone makes a mistake, the automatic response is not blame and punishment; it is to explore what went wrong in order to fix and learn from it. ‘People must feel that if they tell you something, they’re not going to get into trouble, otherwise they won’t tell you when things go wrong, and they might even try to cover them up,’ says Brailsford. ‘That doesn’t mean they won’t get told off or face administrative action or get sent for extra training, but it means they’ll be treated in a just manner befitting what happened to them, taking into account the full context. If you make a genuine mistake and put up your hand, we will say thank you. The key is making sure everyone understands that we’re after people sharing their errors rather than keeping it to themselves so that we’re saving them and their buddies from serious accidents.’
RAF Coningsby rams home that message at every turn. All around the base, in hallways, canteens and even above the urinals, posters urge crew to flag even the tiniest safety concern. Toilet cubicles are stuffed with laminated brochures explaining how to stay safe and why even the smallest mishap is worth reporting. Hammered into the ground beside the main entrance is a poster bearing a photo of the Station Flight Safety Officer pointing his finger in the classic Lord Kitchener pose. Printed above his office telephone number is the question: ‘So what did you think of today?’ The need to admit mistakes is also baked into cadets at military academy. ‘It’s definitely drilled into us from the start that “we prefer you mess up and let us know”,’ says one young engineer at RAF Coningsby. ‘Of course, you get a lot of stick and banter from your mates for making mistakes, but we all understand that owning up is the best way to solve problems now and in the future.’
The RAF ensures that crew see the fruits of their mea culpas. Safety investigators telephone all those who flag up problems within 24 hours, and later tell them how the case was concluded. They also conduct weekly workshops with engineers to explain the outcome of all investigations and why people were dealt with as they were. ‘You can see their eyebrows go up when it’s clear they won’t be punished for making a mistake and they might actually get a pat on the back,’ says one investigator.
Group Captain Stephanie Simpson, a 17-year veteran of the RAF, is in charge of safety in the engineering division at Coningsby. She has quick, watchful eyes and wears her hair scraped back in a tight bun. She tells me the new regime paid off recently when an engineer noticed that carrying out a routine test on a Typhoon had sheared off the end of a dowel in the canopy mechanism. A damaged canopy might not open, meaning a pilot trying to jettison from the cockpit would be mashed against the glass.
The engineer filed a report and Simpson’s team swung into action. Within 24 hours they had figured out that an elementary mistake during the canopy test could damage the dowel. There was no requirement to go back and check afterwards. Flight crews immediately inspected the suspect part across the entire fleet of Typhoons in Europe and Saudi Arabia. The procedure was then changed to ensure that the dowel is no longer damaged during the test.
‘Ten years ago this would probably never have been reported – the engineers would have just thought, “Oh, that’s broken, we’ll just quietly replace it,” and then carried on,’ says Simpson. ‘Now we’re creating a culture where everyone is thinking, “Gosh, there could be other aircraft on this station with the same problem that might not be spotted in future so I’d better tell someone right now.” That way you stop a small problem becoming a big one.’
Thanks to Patounas’s candour, an RAF investigation discovered that a series of errors led to the near miss above the North Sea. His own failure to hear the order to bank left was the first. The second was that the other pilots changed course even though he did not acknowledge the fresh heading. Then, after Patounas overshot, the whole team failed to switch on their lights. ‘It turned out a whole set of factors were not followed and if anyone had done one of the things they should have, it wouldn’t have happened,’ says Patounas. ‘The upside is this reminds everyone of the rules for doing a Phase 3 VID at night. So next time we won’t have the same issue.’
Others in his squadron are already following his lead. Days before my visit, a young corporal pointed out that certain procedures were not being properly followed. ‘What she said was not a particularly good read, but that’s going in her report as a positive because she had the courage of her convictions to go against the grain when she could have been punished,’ says Patounas. ‘Twenty years ago, she wouldn’t have raised the question or if she had she’d have been told, “Don’t you say how rubbish my squadron is! I want my dirty laundry kept to me,” whereas I’m saying thank you.’
The RAF is not a paragon of problem-solving. Not every mistake or near miss is reported. Similar cases are not always dealt with in the same manner, which can undermine talk of a ‘just culture’. Some officers remain sceptical about persuading pilots and engineers to accept the virtues of airing all their dirty laundry. Many of the mea culpa columns in Air Clues magazine are still published anonymously. ‘Sorry’ remains a hard word to say in the RAF.
Yet the change is paying off. In the first three years of the new regime, 210 near misses or errors were reported at RAF Coningsby. Of these, 73 triggered an investigation. In each one, steps were taken to make sure the mistake never happened again. ‘Given that we never reported near misses before, that’s a quantum shift, a big leap of faith in people,’ says Brailsford. ‘Instead of putting a plaster over problems, we’re now going deeper and dealing with them at their root. We’re nipping problems in the bud by stopping them before they even happen.’ Other air forces, from Israel to Australia, have taken notice.
Adding the mea culpa to your problem-solving toolbox pays off beyond the military. Take ExxonMobil. After the epic Exxon Valdez oil spill off the coast of Alaska in 1989, the company set out to catch and investigate every screw-up, however small. It walked away from a large drilling project in the Gulf of Mexico because, unlike BP, it decided drilling there was too risky. Safety is now such a part of the corporate DNA that every buffet laid out for company events comes with signs warning not to consume the food after two hours. In its cafeterias, kitchen staff monitor the temperature of their salad dressings.
Every time an error occurs at an ExxonMobil facility, the first instinct of the company is to learn from it, rather than punish those involved. Staff talk about the ‘gift’ of the near miss. Glenn Murray, an employee for nearly three decades, was part of the Valdez clean-up. Today, as head of safety at the company, he believes no blunder is too small to ignore. ‘Every near miss,’ he says, ‘has something to teach us if we just take the time to investigate it.’
Like the RAF and Toyota, ExxonMobil encourages even the most junior employee to speak up when something goes wrong. Not long ago a young engineer new to the company was uneasy about a drilling project in West Africa – so he temporarily closed it down. ‘He shut down a multi-million dollar project because he felt there were potential problems and we needed to pause and think it all through, and management backed him,’ says Murray. ‘We even had him stand up at an event and named him Employee of the Quarter.’ By every yardstick, Exxon now has an enviable safety record in the oil industry.
Mistakes can also be a gift when dealing with consumers. Four out of every five products launched perish within the first year, and the best companies learn from their flops. The Newton MessagePad, the Pippin and the Macintosh Portable all bombed for Apple yet helped pave the way for winners like the iPad.
Even in the cut-throat world of brand management, where the slightest misstep can send customers stampeding for the exit and hobble the mightiest firm, owning up to mistakes can deliver a competitive edge. In 2009, with sales tanking in the United States, Domino’s Pizza invited customers to deliver their verdict on its food. The feedback was stinging. ‘Worst excuse for a pizza I’ve ever tasted,’ said one member of the public. ‘Totally devoid of flavour,’ said another. Many customers compared the company’s