I spent a while flying for an offshore operation owned and operated lock, stock and barrel by an oil company. Operations were some what laissez-aller, which I must say at the time I enjoyed. Just like being back in combat but with out the shooting. The company then had a gas explosion which killed two and injured eight. The company attempted to lay the blame at the feet of one individual but a subsequent Royal Commission found him blameless. Sociologist Andrew Hopkins, who was called as an expert witness to the Royal Commission, in his book "Lessons From Longford", wrote, "The accident was quite preventable. It was caused by a series of organisational failures: the failure to respond to clear warning signs, communication problems, lack of attention to major hazards, superficial auditing and, as much as anything, a failure to learn from previous experience. There is nothing unusual about any of this - organisational failures lie behind most major accidents.”
When I left six years after Andrew wrote this it was still just as applicable.
I took to looking at how we operated flying wise having noted the company’s stance at the Royal Commission and put forward the following scenario.
Departing Platform X with six hundred pounds of fuel and eleven passengers when, shortly after rotation, the crew experience a catastrophic engine failure. (operation had three catastrophic failures in a short period of time)
After becoming safely airborne and carrying out the necessary drills, course is set for Home Base.
Shortly after Home Base advises that they are closed due to weather and all aircraft are to shut down off shore. (standard operating practice but not in accordance with directives – were was that land based alternate we were required to carry for all offshore operations?)
The crew advises that they will proceed to Airfield Y for an ILS. (low fuel lights would probably be on at completion as we only carried 30 min VFR reserve)
On contacting approach at thirty miles the crew are advised that the ILS has been unavailable for the past week due to programmed maintenance. (never received notams – or weather)
A decision is made to carry out a 27 GPS approach.
Prior to commencing the approach the current weather of 100 feet overcast and 200 metres RVR is received.
The crew arrive at the MDA and are still IFR and a decision is made to continue the descent.
Cloud break is made at 70 feet on the RADALT and the crew suddenly become aware on becoming visual that the speed is back to 30 knots with a very high rate of descent.
They are unable to arrest the descent before the helicopter impacts the ground. In the ensuing break up the aircraft is destroyed and a number of persons suffer fatalities and injuries.
Question: Accidents are made up by, what seems at the time, seemingly inconsequential events. Is it possible for the above sequence to take place? Do we have the necessary controls in place to avoid such a sequence taking place?
No acknowledgment of receipt, discussion or any thing else ever happened.
In an endeavour to reinforce the message the following incident report was made through the in house reporting system. “I was detailed as Pilot in Command of an aircraft (one of three) on the 0730AM flight. Engine start was made at 0727AM and the flight commenced. The weather forecasts prior to departure called for fog on the Area Forecast until 12 Noon, and the Terminal Aerodrome Forecast (TAF) for Airfield Y called for fog reducing the visibility to 500 metres until 1100AM.
On becoming airborne fog was seen some two kilometres north east of Home Base, with a one to two knot north easterly wind blowing. The two other aircraft landed at Home Base as we were approaching Platform K, following our departure from Platform S. We had asked Home Base (not an approved observer) for an appraisal of the weather and as we were taking off from Platform K Home Base called. We asked him to stand by as we were in the middle of the take off procedure and when safely airborne we asked for him to pass his message, which was that fog was beginning to form and suggested we might return to Platform K. Without prompting he noted we possibly did not have the fuel to do so, and as we could see that the land was clear to the south of Home Base a decision was made to proceed towards Home Base, and if necessary a landing would be made in a paddock where the fuel tanker would have easy access. On arrival broken fog had formed over Home Base and a descent was made in the clear about one kilometre to the SW and a right base flown to 09 runway at 100 feet AGL. Visibility crossing the threshold was 2,000 feet (fog bank sitting on the upwind end of the runway) and by the time of shutdown three minutes later had reduced to less than 500 feet. Shutdown was made at 0915AM with 318 pounds of fuel remaining. That is, the aircraft had fuel remaining for three minutes and some seconds of further flight with out impinging on the 30 min statutory reserve. A Level A report was made to management in an endeavour to reinforce the point made by the submitted ‘Safety Exercise’ above. That is, had we had an emergency such as an engine failure shortly after take off from Platform S we would have had no runway available as demanded by the regulations upon which to effect a safe landing, as the reduced single engine speed meant we would have arrived at Home Base after the fog had rolled in and with no fuel to pursue a safe alternative.”
This received a response. Management advised “you are to do what you are told”. They were unconcerned about the incident or its implications, the only concern being that a report now resided on the company computer awaiting the “discovery” process of any legal action. My yearly appraisal from the chief pilot after this stated “Bloggs has a manner that is often difficult to relate to and an approach to management that is difficult to supervise. I believe that whilst this is how Bloggs comes across there is no malicious intent or scheming in his actions. Bloggs gets some out of perspective concerns as to how some things should/must be done which is where he has alienated successive managements over the years.”
Difficult to supervise? No, but if you want to lead you should at least know what your own Ops Manual/Regs say
Out of perspective concerns? Yes, if you consider that not complying with the law is quite OK
Alienated successive management? Well I hope so – the last thing a manager wants is to be held accountable.
PS I got a letter, along with two other pilots, advising “we are pleased to advise your salary increase for this year is zero” According to company documentation is not possible to get a zero.
Jay Hopkins wrote in the American “Flying” magazine May ’04 an article “Pressured to take the flight”
It is a well known fact that pilots often feel a very strong, even intense, internal pressure to make a flight, and once in the air to make it to the destination. There are many factors that conspire to induce this headstrong focus on accomplishing the mission. For a pilot building time, every hour in the air gets him that much closer to that coveted airline job. For a pilot paid by the flight hour, every flight turned down means a smaller pay cheque. Then there is the subtle internal pressure to do better than other pilots, the pride of making it in when other pilots couldn’t, perhaps combined with feelings of invulnerability. Even the simple desire to make the client happy by getting him or her to the destination on time can lead a pilot into risky behaviour.
Because of all these factors that can lead a pilot to break the rules and take unnecessary risks, it is critical that pilot managers establish a similarly strong internal culture of following the rules, reducing the risks as much as possible, and never taking unnecessary risks. It is disheartening that in some companies, there is actually significant pressure from management to break the rules in order to make more money and please the client.
Often human nature is at the core of our problems. Every company is in business to maximise profit, and it can seem that the regulations often conspire against making any money. In a competitive market, it can seem expeditious to “bend” the rules a little, or even break them, in the interest of keeping the client happy, getting ahead of the competition and becoming more profitable.
Any operator who is pushing the limits and breaking the rules will have an accident and end up losing all the money they gained and more. An employee who holds to the rules and speaks up in a risky situation can come across as a complainer and can get a reputation of not being a company person, a “team player.” Employees have said their managers told them they were too assertive and they shouldn’t say anything any more. On the other hand, an employee who is willing to break the rules and do whatever it takes to complete the flight may be seen as a go-getter, a team player, and be favoured by management. Over time, the complainers often are fired, while the “team players" move up the management ladder. Finally, the person who believes in breaking the rules is put in charge of the operation and even more pressure is brought to bear on anyone foolish enough to turn down a flight because of weather, aircraft performance, maintenance or duty time limitations. To make matters even more difficult, the owners and senior management of the company may not be pilots or have any in-depth aviation knowledge.
The pressure that is put on the line pilot in this type of management environment can be intense. Firing a pilot who refuses a flight can quickly get the rest of the pilots in line, especially in a competitive job market when it may be hard to find another job.
The very nature of these issues makes them hard to overcome. Anyone who tries to speak up and take action is by definition a complainer and may suffer the consequences.
In extreme cases, where it has gotten to the point that people are saying, “Someone is going to get killed,” it is time to call the FAA. While this is not an easy step and it could have repercussions for the person’s job, in an environment of risk taking and breaking the rules, sooner or later someone is going to get killed. It could be you, or it could be your best friend. I would rather lose my job than see people die and have another black mark against our industry.
I left the company because it was obvious that remaining in the system could do nothing. What was disappointing was that the ATSB didn’t seem to be interested. A month after making a submission I hadn’t heard anything so rang only to be told it’s a job for CASA. Only hope the chaps just getting started in their careers and with young families don’t have to go through what the young man did at the Royal Commission at the company’s hands. Split the family, and today seven years after the event he is still under psychiatric care.