Accidents caused in part by a lack of oversight or regulatory compliance

[27 L]

Can you give me any suggestions on which significant accidents that were caused by a lack of poor oversight or regulatory compliance, preferably operational failures, rather than maintenance orientated?

Additionally, which airlines have gone bust due to crashes caused by the above?

Many thanks in advance

[Consol]

Manx2, Cork.

[ZFT]

Transasia Taiwan

[Homsap]

B737 at kegworth - Poor judgement by CAA Flight Operations Inspector (FOI) in relation to training requirements when converting on to a EFIS aircraft.

Viscount of Staffordshire, again in part down to the FOI, in relation to checklists and MEL,

[Left Coaster]

Sonicblue. Port Alberni BC Canada.

[safetypee]

An interesting question, but clarification of why anyone would wish to identify these aspects as an isolated safety issue may help with a response.
There is rarely a single 'cause' in accidents. Many reports state probable cause and add contributing factors reinforcing the view that accidents involve many factors and the opportunity for them to come together.
Any views given will be with knowledge of the outcome and therefore will be biased. Our views and contributions depend on what we look for, and then this is what it usually found.

Oversight normally relates to the regulator, typically being cited as an error - hindsight; we like stating 'you should have thought of that before'.

Problems of compliance probably apply more to operators, and can be interpreted in many ways. It is difficult to establish exactly what an operator understood at the time of the event; what was required by compliance, what had the regulator seen, approved, or commented on. Whatever the situation was previously there may be little correlation with a later accident.

The AMS B737 Rad Alt error and MAD MD80 config warn failure are usually reported as 'human error', the crews did not comply with the requirements to monitor and check. However these accidents could be interpreted as issues involving oversight. The aircraft were certificated according to 'grandfather' rights, but with several previous indications of system problems and the availability of self monitoring equipment the regulator could have chosen to mandate a change of equipment. Compare this with the mandate to modify the pitots after ice crystal incidents - before the AF447 accident.

[Sam Asama]

There are certain countries and geographic areas with significantly higher than world average accident rates that correlate with the two mentioned contributory factors (lack of compliance and lack of regulatory oversight -- which of course go hand in hand).

Examples one could use would be xxxxx, and several countries in West Africa, that suffer from a serious lack of oversight (or ineffective oversight) due to various cultural, political, and economic reasons.

Having said that, there are also some "developed countries" that are having issues with funding and staffing of the regulator, which in turn has lead to a lack of oversight and therefore non-compliance laying latent and undiscovered until an accident or major incident brings to light the inadequate regulatory oversight. xxxxxx, as an example, has been on this path for some time now.

Really need to cite supporting evidence before naming names - JT

Google is your friend...

[safetypee]

A quote from a safety blog; 2015.
"An inescapable fact is that the character of an industry is largely a mirror image of the character of its regulators, and, of course, vice versa. Competence, integrity, compliance, and transparency or their lack seldom exists on only one side of an industry-regulatory interface"

[CaptainKirk1950]

Can you give me any suggestions on which significant accidents that were caused by a lack of poor oversight or regulatory compliance, preferably operational failures, rather than maintenance orientated?

Although the NTSB simply blamed the pilot for poor fuel management, the August 13, 2004: An Air Tahoma CV-580 freighter (N586P) crashed during approach to landing at Cincinnati/Northern Kentucky International Airport, Covington, Kentucky, killing the first officer. The cause of the crash was fuel starvation as a result of improper fuel cross-feed application.

I wrote a paper about this one which also listed poor regulation and poor certification as causes. The aircraft had a design where it was possible to cause structural damage during fuel crossfeed. All they should have done (and many did after two accidents) was fit a check valve. (Known as a non-return valve in the UK).

The FAA had allowed for a service bulletin to be issued to upgrade the fuel pumps increasing their output. The accident aircraft only had one fuel pump upgraded. When the PIC left the fuel crossfeed valve open, but changed his mind and did not switch off the high side fuel pump, that increased output pump ran all the fuel into the side with the unmodified pump, causing the fuel starvation to the engines. So, yes, poor regulation and poor certification - but don't hold your breath waiting for the NTSB to make such a finding.

[old,not bold]

Viscount fuel starvation, Exeter (http://aviation-safety.net/database/record.php?id=19800717-0)

Reading between the lines there was a regulatory failure to pick up the lack of proper procedures, behind the more obvious operational failures on the day.

CAUSE: "The accident was caused by the aircraft running out of fuel due to the crew's erroneous belief that there was on board sufficient fuel to complete the flight. The aircraft's unreliable fuel gauges, the company pilots' method of establishing the total fuel quantity and lack of precise company instructions regarding the use of dripsticks were major contributory factors. Meter indications on the refuelling vehicle at Santander, which cannot have reflected the quantity of fuel delivered, are also considered to have been a probable contributory factor."

As an aside, a few days after the incident, an argument in the Gulf Hotel Muscat bar between those who blamed the Captain for failing to ensure adequate fuel was on board, regardless of how difficult that might have been (dripsticks etc), and those who regarded him as blameless because he was told it was OK, ended in an unseemly brawl involving locally-based GF pilots and visiting GF long-haul crews.

[Sidebar]

For a more recent example, see Aviation Investigation Report A13H0001 - Transportation Safety Board of Canada (http://www.tsb.gc.ca/eng/rapports-reports/aviation/2013/a13h0001/a13h0001.asp).


Findings as to causes and contributing factors:
10. Transport Canada's approach to surveillance activities did not lead to the timely rectification of non-conformances that were identified, allowing unsafe practices to continue.

11. The selection of the corrective action plan process as the sole means of returning Ornge Rotor-Wing to a state of compliance resulted from the belief that other options were either unavailable or inappropriate for use with a willing operator. This belief contributed to non-conformances being allowed to persist.

12. The training and guidance that was provided to Transport Canada inspectors resulted in uncertainty, which led to inconsistent and ineffective surveillance of Ornge Rotor-Wing.