Criminalisation of Accidents

[airsnoop]

If I was an LAE, I'd be worried - Concorde, Helios and now Spanair. It seems the first head to roll is an engineer even when those in the business know he/she has done nothing wrong - and none of the organisations that postured on the Joint Resolution (FSF RAesoc etc) are standing up and being counted. What is happening?

[Litebulbs]

I am and I am very worried. It appears even following the maintenance manual is not enough!

[Genghis the Engineer]

I've been involved in the defences of two CAA prosecutions, one of a pilot for reckless negligence (after he made a mess of an approach and ) and one of an inspector who signed something off which failed, causing two deaths).

It does seem to be CAA's standard response now to be seen to be prosecuting somebody after an accident is publically visible. I don't think that they have a strong view on who they prosecute, although easy targets seem preferable.

To the best of my knowledge, RAeS has taken no view on this at-all. Maybe it should, I'll see if I can ask somebody important.

Personally I think that the whole blame culture just gets in the way of stopping accidents from recurring, but it seems to make the proletariat happy!

On the other hand, I know of a case where the widow of somebody killed in a one-off flying machine (sorry, I'm not saying what in public) which arguably should never have been allowed to fly tried to take the CAA to court. They ran up around a quarter of a million's worth of legal bills, then showed her the accounts and simply offered to forget about it if she dropped the case. It would be nice, wouldn't it, if everybody the CAA prosecuted had such bottomless pockets so that they could defend themselves on a level basis.

G

[Litebulbs]

To me it is all about probabilities. You can check the work you have carried out and if you have used the correct tools, that should be enough. If you are supervising someone, you get to know there abilities and help when required. Now if we are moving to an area where you will be charged with criminal negligence and involuntary manslaughter, then you have to build up the safety net around you. Ask for duplicate inspections on every thing that you do. Insist on 100% supervision on staff unable to release their own work. Do not trust anyone or any procedure or manual. Do not defer any defect until the problem has been thoroughly investigated and the cause established.

Now you will increase the protection that you will require to avoid possibly going to jail. Now, who protects you from your employer? In all probability, you would not have made a mistake that would endanger anyone, but you will definitely be causing a problem to the operational performance of the company that you work for. Your company will say that it has various systems in place to ensure the safe operation of aircraft and that they are a no blame culture. However, as has been seen, prosecution of engineers is no longer anything that they can protect against.

[happybiker]

Genghis you appear to make a sweeping statement that it is a CAA standard response to prosecute after an accident becomes visible whatever you mean by that. This is clearly not the case and to the best of my knowledge there has not been a large number of prosecutions of engineering staff by the CAA. If there had been I am sure the media would make the most of it.

However where there is evidence that the safety of an aircraft has been recklessly or negligently endangered by the actions of a person then the regulator would be failing in their responsibilities if this was not followed up. Such prosecutions do not occur frequently.

It is also worth noting that prosecution for manslaughter is a matter for the Police and not the regulator

[NutLoose]

LitebulbsI am and I am very worried. It appears even following the maintenance manual is not enough!

I could not agree more......... Christmas I was involved in the repaint of some Cessna 152's and rebalancing the controls.......... By the Cessna 152 book the figures were all wrong, even the picture of the aileron in the books were wrong...... Contacting Cessna it turns out the book is wrong and has been since the year dot........ They are issuing what ever they issue to get it corrected......... but makes you wonder what everyone else in the Industry had been using to balance theirs for the last 38 odd years..

[MD11Engineer]

A Spanish contractor working at our station told me today that there has been a demonstration of Spanair engineers and mechanics against the prosecution of the engineer involved in the MD-80 crash.
According to him, the Spanish minister of transportation has been given out orders to find somebody guilty, so that she can show to be tough to the press (which, as this colleague told me, apparently is now running a witch hunt againstz Spanair).

[airsnoop]

The "Joint Resolution regarding the Criminalization of Aviation Accidents" dated 17 October 2006 was signed by Flight Safety Foundation; CANSO;ANAE and RAeS. Very good at the posturing but when it actually happens and they need to stand up and be counted, they seem to go to ground.
Apparently, there is to be a 'show trial' in Cyprus of five Helios employees so watch this space.

[airsnoop]

I agree with happybiker, at least the Authority knows something about the business - it is the national judicial bodies who take over the Annex 13 investigation and know nothing about aviation, that worry me.
Like he Helios engineer who it is alleged left the pressurisation selector in 'MAN' - he didn't, but even if he did, since when have engineers configured the flight deck for flight - try explaining that to a court!

[Genghis the Engineer]

Genghis you appear to make a sweeping statement that it is a CAA standard response to prosecute after an accident becomes visible whatever you mean by that. This is clearly not the case and to the best of my knowledge there has not been a large number of prosecutions of engineering staff by the CAA. If there had been I am sure the media would make the most of it.

However where there is evidence that the safety of an aircraft has been recklessly or negligently endangered by the actions of a person then the regulator would be failing in their responsibilities if this was not followed up. Such prosecutions do not occur frequently.

It is also worth noting that prosecution for manslaughter is a matter for the Police and not the regulator


Of course it's not absolutely universal, and yes a manslaughter prosecution is a CPS/police action - albeit in the one I saw, clearly CAA supported.

CAA do not prosecute every case, and not every case they prosecute is inappropriate - but they do like going for the easy targets rather than the most appropriate in most cases.

G

[Exup]

While I agree with some off the comments above lets get this in to prospective, while everybody strives not to make mistakes we all will at one time or another its the nature of the job. These mistakes are kept to the absolute minimum by the professionalism of the people involved & the systems around us (although not perfect ones) with this in mind the chances of being involved in a major incident are extremely remote & even if you were the prosecution would have to prove neglegence of one type or another. If we go around concerned that our every act or decision is going to have us banged up in some jail we will only increase the chances of making mistakes & the pressure of what can already be a stressful job.
With all that said I wish the engineers involved in the case in Spain all the best as by all accounts it looks as if they did nothing wrong & do not warrant the problems they are having.

[MD11Engineer]

But where does neglicience start?
In thecontext of a line station, with limited means, I have in most cases stood my ground (especially in all really serious cases, where in my opinion air worthiness was compromised) against management pressure.
But how do you deal with management, if they e.g. refuse to buy certain tools or equipment required for maintenance tasks, based on purely economical calculations (e.g. the tool costs so and so many dollars. How often do we need the tool? How much can we charge the customer for using it? How long until we have recovered the expenses?), but still demand that the customer has a fleet of airworthy aircraft on time in the morning. As a result you are forced to deviate from the AMM, by inventing alternative procedures (which are in 99% of the cases just as safe for the final product (the operating aircraft), but may involve health and safety risks for the engineer while doing the job). As an example, I've tried for years to get a small portable generator and a halogen light on a tripod to use when working on our darker parking positions, instead of working with a torch stuck in the armpit. No luck so far).
I have to say that in my career I've never signed off an aircraft I was not perfectly willing to fly in (and I have done so in the past several times to pacify the crew).

IMO, there are too many operators on the market now who want to playin the big league (competing with the big boys of e.g. BA, LH etc.) but who onlywant to invest at county league level.

Another issue is the pressure handed over by the operators (the airlines) for keeping the flight schedule. In our airline turnarounds are VERY short, any MX action results directly in a delay and we have to justify ANY delay of more than 5 minutes.
Luckily the airline maintenance control staff are very professional and I never had an issue in my current job when I had to ground an aircraft, as long as I could give a reasonable explanation (in a previous job I had issues with a customer manager, who tried, without success, to force me to release an aircraft with a known problem, which IMO affected airworthiness, because he "didn't want a delay on his shift").

Concerning the Madrid accident, reason (and rules) say that the engineers should have done the complete T/S procedure, which might have taken them several hours and would have surely canceled the flight, before entering the MEL.
Doing this procedure, they would have certainly found the faulty relay. But on the other hand I can well imagine the b*ll*cking they would have received from their managers should they have canceled a flight to find in the end that it was just a faulty probe heat element, which was perfectly deferrable.

It is very possible, especially if the company culture puts a lot of pressure on the individual engineers) to develop a "tunnel vision" when troubleshooting, to find what one wants to find, just to get the plane moving (this is actually one of the "Dirty Dozen").
The individual mistake might not be big enough to bring the aircraft down, but it is another hole in the cheese slice, which lines up with others.

[Rigga]

Management and commercial pressures aside; There has always been the threat of legal actions being taken against any engineer/mechanic who has been involved in the failure of a system they had signed off at some time in the past. (JAL 747 Rear Bulkhead failure had been repaired more than ten years previously - if I remember rightly?)

Some months ago two NZ heli engineers got jailed for their supervisory neglect causing two deaths - and after reading the story, quite rightly so.

We are (advised) supposed to sign off "In Accordance With..." in order to minimise the risk of litigation - not because some jumped-up QA idiot likes it that way!

Commercial Air Transport operations now mean that we are not ''allowed'' to give Judgement on the state of an aircraft any more - we must rely on being given instructions and to carry them out to the best of our ability - though we must always be aware of danger signs as they arise. (I like to think that is why we are different to car mechanics)

I am led to believe (and hope) the Helios case will fall flat due to the engineer signing up "IAW" correctly.

Even if there is some little-read phrase deep in Boeing manuals to return switches to their last setting (wherever that may be), Pilots are ultimately responsible for doing adequate FRC "checks" prior to Take Off.

[Blacksheep]

If I was an LAE, I'd be worried - Concorde, Helios and now Spanair.Concorde, Helios and Spanair all took place in countries that do not practice Common Law (aka English Law):

Civil Law procedures are quite different to the Common Law accusatorial situation. In Common Law a person is accused of a crime and an adversarial contest ensues between the prosecution and the defence to establish guilt. In Civil law, the judge inquires into a situation to determine if a crime has actually been committed and if so, who was responsible. The judge acts as an inquisitor and both defence and prosecution answer his questions. The philosophies underlying each system may be hard to differentiate but the differences are real enough. The Civil Law process is a bit like the MEDA investigations that we conduct in-house when a maintenance error is assumed to have occured.

In either case, amongst the questions the (Civil Law) judge or (Common Law) jury must assess are: were the proper procedures followed; were those procedures properly drafted and how was the work authorised? A complicating factor, at least in England & Wales, is that under the Law of Tort, an employer is responsible for the acts or omissions of his employee unless the employee can be shown to have been "on a frolic of his own."

If you are properly trained, approved & authorised, used the proper tools and test equipment and followed all of the relevant approved manuals exactly as written you have nothing to worry about. Unfortunately, under the pressure that is subtly applied to avoid delays, we are often enticed into taking short cuts. In each of the three quoted incidents there appear to have been some deviation from established procedures or else certain (subsequently) unjustified assumptions were made. Whether these are examples of LAEs going off on "frolics" of their own is debatable. The man on the Clapham omnibus must decide.

Don't assume. Check.

Even if there is some little-read phrase deep in Boeing manuals to return switches to their last setting (wherever that may be), Pilots are ultimately responsible for doing adequate FRC "checks" prior to Take Off.Little read it may be, but hardly deeply set, the last paragraph of a Boeing AMM Test Procedure is "Return the aircraft to its usual condition". That is, circuit breakers closed, all switches in the off or ground position.

[west lakes]

From a different industry but with similar philosophies

This subject has been discussed at length here and with regulatory bodies.

It is important to look at the events leading up to any accident (hate that word) to decide the possible actions by regulators

Example 1
Work being carried out, all the required and correct tools in use, all procedures being carried out per the books. An engineer catches his arm on something and a piece of equipment shifts/drops and causes damage.
That is the sort of incident that would be looked at as no blame.

Example 2
Work being carried out, the book specifies a particular process, piece of equipment or tool to be used. For whatever reason a decision by the engineer(s) to do it slightly differently because it is easier, not use that to piece of equipment as it is heavy or bulky or needs transported to site or not to use that tool because an alternative is easier to use. As a result damage or an incident occurs. This is the sort of situation where blame/prosecution could be envisaged.

You should be able to see the subtle difference in the cases.

Within the industry I work in an incident occurred leading to severe injury to a couple of non-employees (one of them very severe). Investigation showed that communication from site to the "centre" was poor but the person on site had ignored and broken a couple of safety rules that were in place to ensure safety, whilst a prosecution has not (to my knowledge) been instigated senior staff and others were interviewed under caution. The on site person has been disciplined (and may lose his job) for the breeches of the rules that led to the injury. This all with the involvement of the appropriate union.

It is a fact of life that tools, equipment and resources can be unavailable for a number of reasons, that commercial pressure can be brought from those not in the know - this applies to all industries.
The only defence is to shout long and hard AND IN PRINT TO YOUR EMPLOYERS about the shortcomings. Why in print - so you have evidence that you had made management aware of the problem.

Commercial pressure is a bit different, I have however found that the simple request of "if you are instructing me to ignore procedures then put it in writing - now" to those exerting pressure can make then stop and think.