Natalee Johnston grew up in regional Western Australia and is the Royal Australian Navy’s first female pilot. In her 24 years of military service, Natalee fulfilled roles as a qualified helicopter instructor, operations manager, leader and safety professional. In these roles she has gained knowledge and practical skills in understanding human behaviours, why we make errors, what influences our decisions and how organisational culture impacts it all. She has over 15 years of experience in instructing and facilitating helicopter training, risk management, safety investigation techniques, human factors, non-technical skills and positive safety cultures. 

Since leaving the military, Natalee has provided consultancy services specializing in Safety Management Systems, Human Factors and Safety incident investigation to Boeing Defence Australia and TOLL Aviation. She has delivered decision-making, communication, and organisational culture workshops based on the principles of understanding human factors to a variety of organisations ranging from safety professionals, defence, and maritime industry to service and hospitality providers. Natalee is an international keynote speaker and has shared her safety expertise and career journey with a wide range of industries. 

Natalee holds a Bachelor of Science degree in Physics, Post Graduate Certificate in Accident Investigation, a Diploma in Lead Auditing, Diploma of Security and Risk Management, Advance Diploma of Work Health and Safety and a Masters in Business. 

Introduction 

The aviation industry is an ecosystem of professions from aeronautical engineers, manufacturers, and maintainers, to baggage handlers, air traffic control, schedulers, flight attendants and pilots. They all have a crucial part to play in ensuring the safety of all who fly. Due to the combination of components, and the sometimes-unpredictable nature of the physical environment, it is a high-risk industry. In which one seemingly small error can result in catastrophic consequences but where also a single decision can avert catastrophe. This is no different from all industries, accident investigations and risk management methodologies can make positive changes to not only the safety of workers but also the bottom line. 

Relationship between Risk Management and Accident Investigations

Investigations and risk management must both be present and effective to have a safe system. If investigations are superficial and focus on individual acts only, then the systemic influences and impacts will remain, and a similar incident will occur potentially with greater consequences. If risk management is poorly understood, it can result in a hazard not being identified or critical controls not being captured resulting in the risk being realised and an accident occurring. 

Investigation – Determine Why

When accidents occur, people want to understand what happened. An investigation is initiated, either internally within the organisation or by an industry body. The first step involves discovering what occurred, followed by determining how it happened, this then often leads to identifying who executed the act and made the decisions. If an organisation concludes the investigation once the individual or team considered accountable has been identified, the climate that enabled the accident to occur will remain. Additionally, if the person or people deemed responsible are dismissed without any other changes, it is likely that a similar accident, potentially with worse outcomes, will happen again. It can also foster a negative culture where individuals refrain from admitting or reporting mistakes and errors out of fear of reprisal. A deeper understanding of the reasons behind the accident is necessary to cultivate a positive culture, enhance learning and safety throughout the system in which the accident took place. 

Aviation industry Approach

In the aviation industry, accident investigations go beyond identifying who, they instead look to determine why and what influenced or impacted the individual (human factors), including what contributed to the conditions that led to the actions and decisions made. The industry aims to determine how work is done vs work as imagined. 

Investigators examine the individual act in the context of preconditions, the role of supervision, and the organisation itself. Preconditions include health and well-being, the physical environment, training, knowledge and skills. Supervisory factors include micromanagement, the absence of supervision and everything in between. Organisational considerations are everything from resourcing to processes to the one that impacts them all: organisational culture. 

Courtesy of the Royal Australian Navy

The role of Risk Management in investigations

To aid in identifying systemic failures, absences or successes; the investigator includes the review of the organisation’s (unit, team), risk management to assess if the hazard had been previously identified. If yes, had the associated risk been evaluated and what was the effectiveness of existing controls. Once the systemic factors are identified the investigator outlines their findings. These findings point to the climate that existed to create the environment that allowed the error or mistake to occur and the risk control to work or not. Investigators can also use the analysis of controls to aid in seeing what worked, and what enabled the error to be captured before catastrophic outcomes. This provides an opportunity to make lasting changes. The investigator then develops recommendations with the aim to prevent future reoccurrence and/or reduce future consequences. The effectiveness of the recommendations depends upon industry or organisation acceptance and the subsequent successful implementation. 

To tap into the benefit from the findings and recommendations; an organisation should evaluate its identified hazards, risks and established controls to guide system improvements. Initially, the identified hazards should be reviewed to  ensure reasonable assessment of the risk has been applied post the finding from the investigation. Next, the current controls should be reviewed to determine whether any need to be removed, amended or added to reduce the risk likelihood or the resulting consequence. Diagram based on Bowtie Risk Methodology (UK CAA, 2025)

Risk Control Review 

Many organisations, post an accident, want to be seen to make change, to act. Often the solution is to add a control. Those added are often administrative (policy, procedures, a sign or poster, toolbox talk), one that requires people to act. But how effective are they at prevention or reduction? Organisations should recognise there is a critical mass to what people can recall. Over time, administrative controls can lose their effectiveness as they rely on people to “do the right thing”. An overabundance of administrative controls can mean it becomes impossible to know them all, even if we demonstrate safe behaviours. For example, an Emergency Nurse is expected to know at approximately 50-100 policies and on average they know 3-5. Many overlap each other and potentially have been added post an incident without consideration of what could be removed. The principles of the hierarchy of controls should be applied in the first instance but removal of inappropriate controls should also be considered. A control could be considered for removal if, when effective, they have no impact on either the risk being realised or change to the outcomes. A review should consider the human factors considerations (pre-conditions, supervision and organisational) and the question must be asked if this control is added has another hazard been created?

Why Wait

An organisation should not wait for an accident to occur to conduct a risk review. The benefits of conducting a risk review are somewhat unquantifiable as it is difficult to record the prevention of an accident. What you can record are successful interventions, changes in effectiveness, reporting and identification of hazards as workers see that managers and leaders consider all layers of the organisation and not solely focus on the individual act. Managers must be willing to invest in improvements in their risk management, as it should evolve with the organisation.  Reassessment needs to be part of any change management, any minor event or unexpected success. 

Lessons learnt 

Recognising that it can be difficult in competitive industries to share post an accident, it is, however, essential for future growth. Risk management and accident investigations should not be in isolation of each other but be conducted together to ensure lessons learnt translate into lasting change to enhance the future. As risk management and control effectiveness improve, lessons learned from investigations and regular risk assessments are integrated, organisations can build resilience against unforeseen events and ensure a safer operational environment. Furthermore, sharing these insights across the industry can contribute to collective safety and innovation, strengthening the overall framework within which aviation operates, and thereby maintaining its status as the safest mode of travel.