External pressure affecting pilot decision making.

[dhc2widow]

There are several Canadian cases which fit this mold of external pressures and ineffective management ...

A pilot was recently convicted of criminal negligence in a 2002 crash which resulted in one death, and the injury of others. This is a link to a newspaper article http://www.winnipegfreepress.com/loc...-4671470c.html and this is a link to the Canadian TSB report http://bst-tsb.gc.ca/en/reports/air/...4/A02C0124.asp which concludes with theses findings:

Findings as to Causes and Contributing Factors

1. The pilot did not correctly calculate the amount of fuel required to accomplish the flight from Winnipeg to Gunisao Lake and return, and did not ensure that the aircraft carried sufficient fuel for the flight.
2. The ILS approach was flown above the glideslope and beyond the missed approach point, which reduced the possibility of a safe landing at Winnipeg, and increased the risk of collision with terrain.
3. During the missed approach, the aircraft's engines lost power as a result of fuel exhaustion, and the pilot conducted a forced landing at a major city intersection.
4. The pilot did not ensure that the aircraft was equipped with an autopilot as specified by CARs.

Findings as to Risk

1. The company did not provide an adequate level of supervision and allowed the flight to depart without an autopilot.
2. The company operations manual did not reflect current company procedures.
3. The company did not provide an adequate level of supervision and allowed the flight to depart without adequate fuel reserves. The company did not have a safety system in place to prevent a fuel exhaustion situation developing.

Other Findings

1. The pilot did not advise air traffic control of his critical situation in a timely fashion.

In 1998, Transport Canada completed it's "Safety in Air Taxi Operations" final report (http://www.tc.gc.ca/civilaviation/sy...13158/menu.htm) which includes the following commentary:

When an accident occurs, often the pilot is the only one held accountable. While the pilot may be at fault for having made a poor decision or series of decisions that led to the accident, other questions have to be asked... Were there any systemic problems in the company? What was management’s role in the accident? What did management do to prevent the accident? What is management doing to prevent a recurrence? Management must be accountable for the safety of the day-to-day operations. When management is held responsible for an accident, they will become more proactive in promoting safe operating practices.

There is much food for thought in the document.