External pressure affecting pilot decision making.

[Hobbit]

I am looking for examples of management pressure, possibly inadvertent, affecting pilots in a negative way. Looking at Lockhart River for example, the skipper had almost been endorsed by management to carry out GPS approaches while himself unqualified, the fact that he carried one out on the day of the tragic accident could have been forecast by any of the company's first officers I am sure. By not in some way trying to stop his non-SOP antics, the company management endorsed his behaviour, in my view.

Another example is the low cost carrier approach to pay; when you fly you get paid, obviously when you do not fly you do not get paid. With a wife, two children and a mortgage to pay there is no decision to make, the pilot must fly when sick! The same could be said of the 'commercial' alternate and lower experienced captains; the Company demands the cheapest alternate, even though the weather is less than ideal I must go there.

Any real world examples of this insidious pressure would be much appreciated.

Hobbit

[IGh]

“... looking for examples of management pressure, possibly inadvertent, affecting pilots ... the Company demands the cheapest alternate... Any real world examples of this insidious pressure ... [?]”

Examples? You’ll likely have to infer about any management pressure, the investigators may not explicitly describe that as cause. Other AAR readers/writers have described their own inferences.


_Flight Safety Digest_, May 1991, pgs 1-15;
http://www.flightsafety.org/pubs/fsd_1991.html
C.O. Miller, “Investigating the Management Factors in an Airline Accident”; 28 pages. [PDF 181K]

“The significance of management’s role in the sequence of events ending in accidents is examined and suggestions are advanced that the influence of management be included in accident investigations.”

[From the first paragraph, on pg 1:]
“The management factor in aircraft accident investigation has emerged as a relatively recent phenomenon ... The absence of a specific investigative protocol is only part of the reason ...”

[From the last paragraph, on pg 8:]
“Government authorities should take steps to introduce ... accident prevention management investigation into accident inquiry ...”

C.O. had given two earlier papers on this topic, in ’84 and ’88; and there’s another paper on the weaknesses of later regulatory changes [response to NTSB Recomm A-89-130] that were meant to focus on this management-element [see C.O.’s later paper “Director of Safety”, _Air Line Pilot_, May’96, pgs 34-7].

His Appendix III of that 1991 paper (FSF May’91 pg 15 ) offers some candidate mishaps (AAR’s) for your consideration.

[A37575]

Happens every day in GA ops in Australia - particularly away from the capital cities. Anecdotal evidence reveals majority of GA pilots are very careful not to write up defects in the maintenance release (servicing document) unless specific permission from their management is received. The object being to minimise down time on the aircraft and associated servicing costs (transportation of engineers to remore areas where the aircraft might be stuck). The second objective is hide unserviceabilities from CASA inspectors who might be tempted to show more than a passing interest. Job security is another reason some pilots decide not to officially record maintenance defects. Don't make waves and we'll all be friends...

[alf5071h]

Hobbit, you could consider the recommendation in the Garuda accident report;-
“ … review its fuel conservation incentive program policy to ensure that flight crews are in no doubt about its intent, and that there is no perception that such a policy could compromize the safe operation of aircraft.” Final report. (www.dephub.go.id/knkt/ntsc_aviation/baru/Final%20report%20PK-GZC%20Release.pdf)

Also see Aero Safety World Apr 2007. “When push comes to shove”. ( http://www.flightsafety.org/asw/apr07/asw_apr07_p26-31.pdf)

[Hobbit]

Thanks ALF, I'd already found the Garuda report and was just sitting down to read it. An interesting observation from a young investigation authority.

[Hobbit]

A37575 I hear what you say, but I would define that as active pressure from management. If they didn't insist on you checking with them, but everybody who snagged an aeroplane down route was disciplined on return for something fabricated, i.e. a common thread was the snags in the tech log but disciplinary sanctions were related to something else, that would be more the thread I was looking for. Many low hour pilots put the snags in at the end of the day to ensure that they get those valuable extra hours in their log books, or to 'keep the show on the road?'

[Centaurus]

Hobbit, you could consider the recommendation in the Garuda accident report;-

The Garuda accident report is worth reading and a link to it is on the ATSB website - which is unusual, although I suspect pressure from the Federal government might have something to do with that decision. Aussie diplomatic staff lost their lives in that accident.

The Indonesian report (in English language too) lets the pilot off the hook by saying he may have "channelised" his attention to landing and also was "fixated" on landing. What bollocks. He flew a criminally negligent approach and the first officer was too weak to do anything about it.

[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/local/story/4069704p-4671470c.html and this is a link to the Canadian TSB report http://bst-tsb.gc.ca/en/reports/air/2002/A02C0124/A02C0124.asp which concludes with theses findings:


Findings as to Causes and Contributing Factors

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.
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.
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.
The pilot did not ensure that the aircraft was equipped with an autopilot as specified by CARs.Findings as to Risk

The company did not provide an adequate level of supervision and allowed the flight to depart without an autopilot.
The company operations manual did not reflect current company procedures.
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

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/systemsafety/pubs/tp13158/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.

[jolly girl]

I am curious, Hobbit, why are you asking?
(You may PM me if you would prefer)
jg

[permFO]

Centaurus- Its not unusual for reports that the ATSB have been involved with to have links on their website. The crash of the IL-76 near Dili is another example.