Select Committee on Transport Written Evidence


APPENDIX 39

Memorandum submitted by Christine Standing

THE AVIATION SAFETY SYSTEM: POLITICAL, ORGANIZATIONAL, AND PERSONAL

SUMMARY

  The architecture of a system has a profound influence on organizational processes. If, at the outset, there is an unworkable design then this dynamic will permeate the total system and will emerge at different levels downstream where it will ultimately be seen to be unworkable.

  Government Ministers may not understand how systems dynamics influence safety. As an independent regulator", the UK Civil Aviation Authority is a classic example of how inconsistencies in its structure militate against equitable airline management and impact negatively on the work of aircrew; it compromises safety. This combined with weak procedures in the area of human factors in turn impacts negatively on the work of aircrew. It is an unsafe policy.

  The case presented here demonstrates how the political framework of aviation serves commerce to the detriment of the safety and the health of workers in the industry.

CAA—PARADOXICAL REMIT; UNWORKABLE SOLUTIONS?

  The original remit of the Federal Aviation Administration (FAA) and Civil Aviation Authority (CAA) was purely commercial. [12]However, the regulation of safety was becoming an increasingly urgent need on both sides of the Atlantic. In 1926 the aviation industry in the US pressed Congress to set safety standards. The FAA and its counterpart in the UK, the CAA grew from this need. Former Inspector General of the US Department of Transportations (and a pilot) states that this .....dual mission did not leap out at anyone in 1958....as a glaring paradox" because At its core safety isn't cost effective." With deregulation the industry thrived but no one person monitored the downside—what Schiavo calls destructive competition." [13]Accident rates have been rising. The term `Economic Regulation' therefore, the CAA's remit, is an oxymoron.

  The CAA is not an independent public corporation in the sense that it is a regulator not without conflicts of interest. This is a point that many have made before now. (BALPA; Cranfield University; ASG) Its own Chairman Christopher Chataway said, "...the CAA in the UK finds itself in the position of regulating itself and its own competitors..." [14]What they do not note is that the aforementioned conflicts give rise to problems that are inherent and endemic. They produce conflicting interests downstream at management levels demonstrated in management activities—often described as the "profits over safety" argument. For a fuller description on this type of decision-making in high-risk industries see Professor E. Mumford writing on the double-bind manager and their negative impact in safety-critical industries. [15]Such decision-making is unworkable. In the aviation setting many from the International Civil Aviation Organization (ICAO) onwards warn of the management aspects of aviation `organizational accidents' and indicate the need to implement Human Factors procedures to help managers come to safe decisions.

Flying is inherently dangerous; safety was the main concern for pilots from the earliest days of civil aviation. They trained with safety in mind and with continuing learning and assessment—and still do. Their working context however, regulation, has changed and now these subtle changes have lead to compromises. No one person is monitoring this hidden downside.

  Human Factors is the major area that ICAO wish to see taken into consideration in order to break the current safety impasse. [16]Such procedures are currently almost non-existent. There is no safety management system for administration of aircrew.

AIRLINE MANAGERS' DOUBLE-BIND

  Effective accident prevention can be linked inalterably to effective management." [17]Observations reveal that organizationally accident prevention" and commercial management" are two polarized aspects of airlines. However, in practical terms the former is mainly the remit of aircrew and the latter is mainly the remit of managers. Psychologically this is an unhealthy split—like the psychological concept of `splitting' in the individual, this organizational split is a process by which a mental structure loses its integrity and becomes replaced by two or more part-structures." That it, it becomes fragmented. This can be seen in many airlines where flight crew and cabin crew report to different parts of the organization yet research indicates that they should work as a unit inside an aircraft in flight. [18]Criticisms of how this works in practice is seen regularly in the aviation press where demands are growing that the industry rectifies the problem. [19]

In splitting" the emotional attitude towards the two part-structures is typically antithetical, one object being experienced as `Good' the other as `Bad'"[20] If this attitude becomes part of corporate culture it could lead to aircrew being viewed, maybe unconsciously, as bad" by managers. If such attitudes become habitual they could lead to behaviours that don't support the pilot safety concerns, as illustrated in the Case presentation that follows.

  It is not clear what helps managers to understand the proactive measures and decision-making needed to secure good accident prevention (even if aircrew bring their concerns to their managers.) What informs" their decision-making? Airline managers in the UK need not have any qualifications to fulfil their role; there is no Safety Management System (SMS) for management procedures. There is no systematic accountability for administrative practices or examination of organizational competencies. Research into accidents and incidents reveal management failures (latent conditions) that are contributory factors yet in the case described here those latent conditions that led directly to an occurrence" were not picked up.

  Where accountabilities are concerned there is full accountability for pilots whose responsibilities and obligations are enshrined in law—although they may not know what management deficits (latent failures) have been implemented before they themselves board an aircraft. They have to trust the managers. At the other end of the organizational polarity, management", no managers are likely to report themselves for safety deficits that impact on the work of pilots. Pilots who bring safety concerns may find that their views are thought of as unhelpful—or even outrageous"[21]—an attitude fostered by the polarized nature of airlines. There is a power imbalance.

  One of Gordon Vette's aims, writing about the Erebus disaster, was to understand the political intrigue,...to attempt to bridge the schism between the old guard steeped in the `pilot error' easy option (scapegoat) as against looking at the whole entity, the organisation, the sociotechnical system, of which the operator (pilot) is only one part." [22]He noted,...it is most important that aircrew should not be used as scapegoats for the underlying cause of an accident which is being concealed." [23]Captain Stewart of a major British airline was prosecuted by the CAA for an incident in 1989. They were accused of acting out of malice. No-one was killed or injured. Captain Stewart stated that he had been made a scapegoat before committing suicide. With today's understanding of systems theory this decision to prosecute him may be considered flawed.

  To add to the accountability imbalance the Air Accident Investigation Branch (AAIB) has as its sole objective the investigation of an accident or incident....(which)...shall be the prevention of accidents and incidents. It shall not be the purpose of this activity to apportion blame or liability." In the maritime setting the equivalent organization can apportion blame if it would assist in the purpose of prevention; the AAIB however, is never allowed to consider issues of legal culpability." [24]The case under discussion does not appear on its public database. On enquiry the explanation was, The database... is an AAIB internal database and not that published on the AAIB's Internet website[25] Therefore the public will not be able to access reliable data.

  One contribution to the health and the safety of aircrew is called human factors". Essentially it is about the well-being of the employee. The purpose of investigating human factors is to identify why actions lead to the breakdown in safety defences and result in accidents. This requires determining the related latent failures present at all levels of the organization, including the upper levels of management. [26](It is suggested here that governments may also put latent failures into the system as demonstrated later.)

  New knowledge about human factors needs to be integrated into the aviation safety system and updated regularly in the light of scientific advances.

THE HOUSE OF LORDS SCIENCE AND TECHNOLOGY COMMITTEE FIFTH REPORT. AIR TRAVEL AND HEALTH (2000) [27]

  This body criticized the Regulator, airlines and unions for their lack of attention to aircrew health. The concern was, and still is, not that health is secondary to safety but that it has been woefully neglected." Policy was criticized: The lead on aviation health is, in our view, unacceptably weak... (and) ...in relation to safety....the centre of gravity is not obvious" In which case who advises the Ministers? If it is the DeTR, who advises them? Are they monitoring the downside? [28]

  HSE has general oversight of employees' health and safety, part of human factors, but, as noted in the report,

commercial aircraft are largely exempt from the provisions of UK health and safety at work legislation." As regards the remaining relevant provisions, HSE avoids overlapping responsibilities with CAA under a Memorandum of Understanding, (MoU) leaving the lead essentially with CAA. [29]This MoU is a difficult piece of reading to comprehend and a hurdle for those wishing for clarity. Also, there is a Regulatory lacuna. There is no agency covering the health and safety of persons in aircraft when they are in flight...there appears to be a marked reluctance on the part of CAA to take on responsibility for occupational health and safety issues which they clearly prefer to leave to HSE".[30] In the meantime this area is neglected, and this neglect is perceived to cause morbidity and mortality among aircrew.

  The various disciplines associated with Human Factors" are not being applied in a systematic up-to-date scientific way. What is required is Evidence-based practice. The political framework of which aviation is a part should also be taken into account and brought up-to-date in a systematic way. It is unclear who in this part of the system has the knowledge and authority to take transparent, safe decisions. Who is monitoring the downside?

  The following case summary demonstrates some of these ideas. It was first presented at an Aviation Study Group Meeting held at the Royal Aeronautical Society, London in November 2005.

Case Presentation. Pilot Incapacitation—the Human Factor"

  This case is an example of the outworking of the current policy discussed herein where upstream policies impact negatively on downstream events. The information comes, in the main, from interviews and an Employment Tribunal document. [31]Qualitative research examines the social arrangements at work looking not from top-down, a theoretical stance, but describes from grass-roots levels upwards. It describes the actuality of what is happening rather than what should be happening.

  The Pilot. In a single-pilot commercial operation based at a regional UK airport a pilot became ill in flight. [32]He suffered disorientation and began to lose consciousness. The aircraft was seen (on radar) to descend to within 200 ft of the sea. He says that he cannot remember engaging the autopilot but that he must have done. On landing he was left for nearly an hour alone, coughing and vomiting, without first aid, oxygen or decontamination measures against the suspected cause of his sudden incapacitation—a toxic chemical called FAM30. Instead the pilot manager attended to the aircraft to check it out and to test fly it. Meanwhile a fireman found the pilot slumped in their office and called for medical assistance. Staff found him to be nearly dead on arrival at Hospital.

  The cause of his illness was diagnosed as contamination with a toxic chemical (in the course of his work.) The first aid for this consists of immediate decontamination and medical treatment. He is now registered disabled.

  The personal treatment of this pilot following the occurrence is as follows:

    —    He was blamed by the Senior Pilot in his official report to the CAA. [33]The airline agreed that it contained errors.

    —    An earlier report exonerating the pilot was not submitted to the court despite court orders so to do. The airline denied that it existed. On investigation evidence of this particular manager's benign involvement can be seen in other documents. [34]His recommendations were ignored. He is no longer a Director at this airline.

    —    It also denied the existence of other documents—later produced to the court in photocopy form via another employee who has since died in a fatal accident at this airline.

    —    The pilot was subjected to four investigations" by the airline, focussing on his decision, made under the influence of neurotoxins, to NOT divert. These multiple investigations, one turned out to be a disciplinary", took place over seven months—generally considered by a leading psychologist to be a trauma in itself. The nature of this was to investigate how culpable he was considered to be. [35]

    —    He received no counselling nor assessment for potential Post Traumatic Stress Disorder despite two near-death experiences in one day.

    —    There were various questionable administrative activities associated with the conduct of these investigations".

    —    Furthermore, causal factors, management and organizational issues, were expressly not examined—this is a major deficit and not in accordance with ICAO standards.

    —    He has lost his health, his home, his pension (because he was dismissed within two weeks of it being activated).

  The court found that contributory factors (latent errors) existed in this near-fatal accident: There had been no prior Risk Assessment or adherence to COSHH regulations regarding the use of a toxic chemical. The pilot's earlier concerns about the carriage of dangerous goods were dismissed.

  This pilot has been found guilty of nothing; he was dismissed. [36]This is scapegoating.

  He wrote to the Secretary of State for Work and Pensions who responded that, ...while Logan Air might have made better arrangements for handling and working with FAM30 any breach of health and safety law was minor and so did not merit enforcement action." He dismissed the pilot's concerns about bullying and intimidation. [37]

  The Organization. The court ordered the production of documents relating to the case. The airline refused to produce them thus safety-critical information was not examined. The CEO and high-level managers were heavily criticized by the Court:

    —    The respondents had unfairly dismissed the applicant" and we considered unreasonable (and untruthful)...(a senior manager's)...claim that there was little purpose in conducting a further assessment"[38]

    —    The CEO's evidence, was not genuine"[39] and it seemed to us that either he was withholding information asked of him, or, if as he so often repeated, I can't recall", then plainly the reason was because of his total disinterest in the details of the case, the events of which admittedly took place..." [40]

    —    He was, a most disappointing, unsatisfactory and unwilling witness"[41]

    —    The Court stated that, By necessitating a continuation of the hearing on 18 March due to the respondents' omission in complying with the orders, they had, in our view, conducted the proceedings unreasonably...".[42]

  There was not enough time for the pilot to submit all of his evidence. The airline was fined.

  In a Case Study, Pilot Incapacitation: the Human Factor"[43] it is reasoned that this case has, so far, three broad implications regarding human factors.

    1.  Non-compliance with the court order resulted in a small fine. This risk provided a far better result commercially for the airline than the other possible outcome had they produced all of the evidence required of them—damages for the pilot—now disabled. These documents may have helped the pilot's case. It is a human factors failure; it is a case of the success of profits over safety. (Under Duty of Care legislation it may also be a breach of trust)

    2.  Systemic safety considerations such as latent failures, and management and organizational factors, were omitted from all of the airline's Accident Investigations. These causal factors are presumably unchanged; the latent errors still exist. There was no structured methodology applied for establishing the applicability of disciplinary action as an aid to decision-making. Instead Captain Sayers was told that he, jeopardized both himself and his passengers safety" yet the CAA have closed their files on this matter, without censuring the pilot or the airline. (Unsafe)

    3.  The Secretary of State for Work and Pensions, if not correctly appraised of knowledge about systems failures and latent conditions, endorse what may at first glance look like failings of a minor nature. In a single pilot operation incapacitation is NOT of a minor nature. (Policy failure leading to active failure)

  It is not unreasonable (from the logic followed by the CEO) that should avian `flu be detected in his region similar dynamics and inadequate safety procedures to those noted at the Tribunal will be in evidence again. This to the detriment of public safety.

  There had been no AAIB investigation because this occurrence had not been reported to them. [44]

  This airline has had five fatal crashes in 10 years—one in March 2005. This should alert the Regulators (and the public) to potential offences regarding primary duty of care towards aircrew and passengers and the systemic implications.

  Policy. No UK Director has ever been prosecuted or made accountable for contributory actions in aviation accidents[45] ...there are no proper procedures to ensure that deaths and injuries resulting from the fault of.... airline companies are subject to criminal investigation." [46]No person whose contributions allegedly brought about the active failure and disabled the pilot in this case has been made accountable. Non-compliance with Health and Safety law (risk assessments, COSHH nor Whistleblowing) is not a minor infringement in terms of a safety system. It is a latent failure which led to an active failure. What looks minor in the relative safety of an office does not look minor to pilots and their passengers when an aircraft is dropping out of the sky. (The airline blamed the pilot for endangerment.)

  This case raises a further set of issues to do with standards and the non-reporting of incidents and accidents. The UK is a member State of the International Civil Aviation Organization (ICAO). Regarding departures from standards the UK has an obligation to give immediate notification" to ICAO of differences between its own practices and that established by the international standard. Alternatively, in the case of amendments to international standards, any State which does not make the appropriate amendments to its own regulations or practices shall give notice to the Council within 60 days of the adoption of the amendment...or indicate the action which it proposed to take." [47]

  The CAA role was to receive a late report that contained errors. They acted by alerting operators to the dangers inherent in the use of chemicals in and around aircraft. Regarding the incapacitation episode it said that, the pilot was happy to continue." This gives an inaccurate impression. [48]

  The AAIB role was limited due to non-reporting. (Although the pilot had tried to converse with AAIB after being released from hospital.) When later challenged about this they claimed, "As stated in the MOR, the serious in-flight situation was brought about by pilot incapacitation." The systemic failure, that which brought about the incapacitation, was again not examined ie no risk-assessment nor control of substances hazardous to health (COSHH). These, and carriage of dangerous goods, were some the omissions that led to the possibility that contamination with a toxic chemical could occur in the aviation environment. Ie the CEO bypassed procedures that he knew were in place.

  The outworking of policy are seen here to be distorted.

  Discussion. The onus for investigating and defending accuracies in this case has been those of the pilot alone. In his efforts to warn of the dangers of errors in management decision-making he has been met with structures that hinder the exploration of the safety issues. The AAIB stated that they,... "consider that matter has been dealt with comprehensively by the CAA not INVESTIGATED comprehensively. You will have to seek clarification from the CAA as to the processes they used to determine the causes and hence the safety action they deemed appropriate." [49]Should this be the remit of a traumatized former employee?

  There is to be further litigation in this case—funded by the pilot. He alone has been subjected to losses; he is now disabled, traumatized, and the onus is on him to do the work that the public might expect the Regulator to do on their behalf—expose and rectify the systemic safety failings that allegedly led to his dismissal. Captain Stewart, mentioned earlier, stated that he had been made a scapegoat; the pressures on the pilot in the current case are enormous. He considers that it is his army training alone that has enabled him to carry on so far.

  It is noteworthy that in an email from AAIB copied to author dated 10 January 2006, Incident to Islander G-BLDV on 31 March 2001

    "The only recommendation that the AAIB could have made in these circumstances (had the AAIB been informed of the incident and started an investigation at the time) would have been for the CAA to advice operators of the circumstances relating to the incident and warn of the associated hazards. This however, has already been carried out by the CAA in their letter to operators." However, this CAA decision-making and advice to operators was based on the aforementioned erroneous report. While the pilot has requested, and been assured that a correct copy would be sent to him, an airline that refuses to supply documentation to a court is hardly likely to supply it to a former employee. The errors in the causal chain have not been identified nor rectified.

  It has been argued that non-compliance with the court order was a commercial success. It is also the formal point at which no other agency, or the public, could verify what had been happening in an airline that loses so many crew in fatal crashes.

  Psychodynamically, `Does the wider system inadvertently support lack of integrity?" While there was no prior Risk Assessment, adherence to COSHH regulations nor a willingness to listen to an employee's safety concerns, there was also no prosecution or accountability, nor feedback from the pilot into the system. It is not known who advised the Secretary of State for Work and Pensions. He dismissed the pilot's concerns about bullying and intimidation without any process with the pilot; no discussion or feedback before replying. [50]

  This Case demonstrates how:

    (a)  airlines may unwittingly foster a risk-taking culture among its managers;

    (b)  it is the pilot who may be deemed to be culpable in accidents and incidents; and

    (c)  this is an inherently bullying dynamic.

  Organizationally:

    (d)  management decisions influence safety (positively and negatively);

    (e)  non-reporting (or erroneous reporting) of incidents and accidents influence safety;

    (f)  standards may depend on the integrity of individual managers ie may be ad hoc and arbitrary; and

    (g)  the principles of human factors have been omitted from airline management obligations and may be replaced by conflict, culminating in an adversarial attitude towards aircrew.

  It notes that:

    (g)  CAA/HSE are not transparent regarding the human factors element of safety;

    (h)  Ministers may not understand systems theory and safety obligations;

    (i)  no one person/agency is monitoring the downside of deregulation;

    (j)  criminal offences may be overlooked (No evidence found that HSE/CAA have prosecuted the airline for breaches of safety regulations. Court Order was ignored.);

    (k)  the UK may be in breach of Article 38 of the Convention on International Civil Aviation; and

    (l)  there are management training deficits.

  The US former Inspector General of Transportation, (Aviation), M Schiavo, among others, has noted much that is wrong with safety in the aviation industry—the problem is, airlines don't have to take any notice of these observations or high-level research findings; few (if any) people in Government know how to evaluate the problems. If a former Minister in the UK can describe an active failure on board an aircraft, as of a "minor nature",[51] if failures to observe health and safety regulations is "minor", we need to remind ourselves that the lives of all on board the aircraft were threatened—a reportable offence—a lowering of standards. Is this what was intended?

  This paper began by stating that the architecture of a system has a profound influence on organizational processes. This case, after processing by the airline itself, an Employment Tribunal, the CAA, HSE and AAIB, hinged on an interpretation given by a Minister for Work and Pensions. At each stage legitimate objections were raised by the pilot. The Tribunal agreed with the limited number that were presented, but the system allowed the airline to resist the judicial process, cover up its latent errors, send an erroneous report to the CAA, and none to AAIB. This is a systems failure with no feedback loop to ascertain the integrity of the system nor to provide justice for the pilot.

  The case presented here demonstrates how the UK political framework of aviation, so criticized by the Science and Technology Committee and others, is unworkable. This paper demonstrates how it may fail the health and safety of aircrew. The theory offered to explain this is that the architecture of the system is flawed, demonstrated in the day-to-day decision-making that risks the health and life of aircrew and passengers.

  A total revision and the integration of the various disciplines and agencies as a coherent whole would improve the health and the safety of aircrew.

22 January 2006





12   Schiavo, Mary. (1997) Flying Blind, Flying Safe. Avon Books. New York. Back

13   ibid.  Back

14   The Times, (Jan 1996) Regulating Regulators. Back

15   Mumford E (1999) Dangerous Decisions. Problem Solving in Tomorrow's World. Kluwer Academic Plenum. Back

16   Kotaite A (President of the ICAO) July 2000 Plenary Meeting Aviation Study Group, Linacre College, Oxford. Back

17   Miller, CO (1991) Investigating the Management Factors in an Airline Accident. Flight Safety Foundation. Flight Safety Digest May 1991. Back

18   Edwards, Mary. (1992) Crew Coordination Problems Persist, Demand new training challenges. Cabin Crew Safety Vol 27 No 6. Flight Safety Foundation. Back

19   The Flight Safety Foundation has been particularly concerned. Back

20   Rycroft, Charles. (1968) A Critical Dictionary of Psychoanalysis. Penguin. London. Back

21   Standing C (2005) Pilot Incapacitation, The Human Factor. ASG Case Presentation at the Royal Aeronautical Society. Back

22   Vette G with John Macdonald (1983) Impact Erebus. Hodder and Stoughton p 78-79. Back

23   Vette G with John Macdonald (1983) Impact Erebus. Hodder and Stoughton p 12. Back

24   Bergman, David (2000) The Case for Corporate Responsibility. Corporate Violence and the Criminal Justice System. Pub Disaster Action. (p 87). Back

25   Correspondence with AAIB January 2006. Back

26   Human Factors Digest No 10. Human Factors, Management and Organization. ICAO Circular 247-AN/148. Back

27   The House of Lords Select Committee on Science and Technology Fifth Report 15 November 2000 Select Committee appointed to consider Science and Technology. AIR TRAVEL AND HEALTH. Back

28   Note: Ministers have as much of a clue as you or I" in which Minister Ruth Kelly's decision-making regarding the findings that sex-offenders have been employed in schools is analyzed. It calls for a long-overdue review of ministerial responsibility.... Ministers should not make such decisions." It continues, They should do policy-that's their job-and oversee others, such as ombudsmen, special panels and judges, to adjudicate cases fairly." Guardian. Tuesday 17 January 2006. Back

29   Ibid 8.5. Back

30   Henderson, Graeme (2002) Enforcement of Health and Safety on Aircraft SPDA4 2002. Back

31   Employment Tribunal (Glasgow) Case No: S/101767/2002 Andrew Sayers and Loganair Limited. Back

32   Incident to Islander G-BLDV on 31 March 2001. Back

33   Employment Tribunal (Glasgow) Case No: S/ 101767/2002 Andrew Sayers and Loganair Limited. 24/58. Back

34   A Loganair document which references this accident, IH" refers to Ian Huzzard and occurs at Engineering action" and CAA release. (Employment Tribunal (Glasgow) Case No: S/ 101767/2002 Andrew Sayers and Loganair Limited. 27/62). Back

35   Standing C. (2005) Pilot Incapacitation: the human factor. Unpublished Report. From studies on human behaviour we find that under extreme stress pilot judgement can be eroded. Given that physiologically this pilot was under the influence of a toxic substance supplied by his employer how can he be deemed to be culpable? Investigation 3 specifically stated that its reasons for an internal Flight Operations prior to any return to line flying, was,...in respect of your decision to operate the return flight Fair Isle to Tingwall...." (81/168-9)" If Captain Sayers is deemed to be culpable for `ingestion' of FAM30 why is no-one culpable for ordering its use or worse, continuing its use after two incidents?" This is a systems failure that led to an active failure. Captain Sayers' `mistake' lies in drawing attention to this safety deficit earlier in the month. Captain Watt had a choice-he could take notice of Captain Sayers or he could pretend that nothing was wrong-until it became an active failure and an embarrassment to the Senior Pilot. This aspect of this case has never been examined in open court." Back

36   According to the Employment Tribunal, he could have been redeployed. The court heard about lack of proper consultation, failures to ascertain what qualifications the applicant had, which he could have used for the benefit of the company. They noted, ...they would have learned that he was a pilot trainer and flight examiner and was experienced qualified and rated to work in these." Also, Astonishingly, from the time the applicant became fit to work again in late August and despite being in receipt of full pay, they provided him with no work." Thus they broke Clause 22 of his contract. The inclusion of such a clause accorded with Mr Atkins' evidence that it was very rare for a pilot to be dismissed on medical grounds, especially physical injury... the applicant's card was marked and his days numbered" (p 20 line 21) The court found this to be an accurate impression." While Captain Sayers won this case it was overturned at Appeal. It did not investigate how Captain Sayers became incapacitated. Back

37   Letter dated 3 September 200(date Unreadable) to Captain Sayers from Minister of State for Work and Pensions. Back

38   Employment Tribunal (Glasgow) Case No: S/ 101767/2002 Andrew Sayers and Loganair Limited. Observations on the Evidence. S/200741/02 p 20 lines 28-29. Back

39   Employment Tribunal (Glasgow) Case No: S/ 101767/2002 Andrew Sayers and Loganair Limited. Observations on the Evidence S/200741/02 p 19. Back

40   Employment Tribunal (Glasgow) Case No: S/ 101767/2002 Andrew Sayers and Loganair Limited. Observations on the Evidence S/200741/02 p 12 line 24-26. Back

41   Employment Tribunal (Glasgow) Case No: S/ 101767/2002 Andrew Sayers and Loganair Limited. Observations on the Evidence S/200741/02 p 12 line 22. Back

42   Employment Tribunal (Glasgow) Case No: S/ 101767/2002 Andrew Sayers and Loganair Limited. Observations on the Evidence S/200741/02 p 22. Back

43   Standing, C (2005) Pilot Incapacitation: the human factor. unpublished essay. Back

44   Communication: email from AAIB copied to author dated 10 January 2006. Incident to Islander G-BLDV on 31 March 2001. The only recommendation that the AAIB could have made in these circumstances (had the AAIB been informed of the incident and started an investigation at the time) would have been for the CAA to advice operators of the circumstances relating to the incident and warn of the associated hazards. This however, has already been carried out by the CAA in their letter to operators." (based on the aforementioned erroneous report). Back

45   Shipper Jailed after Dangerous Goods Discovery. THE UK Civil Aviation Authority (CAA) has brought a successful prosecution after potentially lethal chemicals were transported on a passenger aircraft. The individual involved, Manu Chandnani of Headcorn, Kent, was sentenced to a total of 12 months in prison for recklessly endangering an aircraft and for causing dangerous goods to be loaded onto an aircraft for shipment. Chandnani sent highly dangerous chemicals, which are banned from carriage by air, on a passenger flight from the UK to Dubai, where the items were discovered in transit to Tehran. Back

46   Bergman, David (2000) The Case for Corporate Responsibility. Corporate Violence and the Criminal Justice System. Pub Diaster Action (p 87). Back

47   Convention on International Civil Aviation. Doc 7300/8 p 17. Eighth Edition 2000. Back

48   Their response was a circular to operators:- Disinfectant kills bugs-hopefully not people! We have been made aware of a possible serious problem by a recent occurrence report, which is still under investigation. As a result of foot-and-mouth precautions....avoid allowing any such disinfectant to remain on one's clothing." (CAA) (148/364) A worrying aspect of the CAA comments is the attitude of blame-that the pilot, intoxicated by a noxious substance supplied by his employer, is described as being happy" to continue the flight and may be interpreted by the company that they endorse the company's position. This wording is partially correct even if the happiness" was chemically induced by a substance that had been carried illegally. This hardly seems to be the correct choice of words in the circumstances-what it avoids saying is that the pilot was too incapacitated to have a choice whether the chemical was to remain on his clothing and is being held responsible while the employer's action-the context-has no mention. Here the CAA are failing to adopt a systems approach. This is simply fire-fighting an event without dealing with the fundamental causes. Back

49   Communication: email from AAIB copied to author dated 10 January 2006. Incident to Islander G-BLDV on 31 March 2001. Back

50   Letter dated 3 September 200(date Unreadable) to Captain Sayers from Minister of State for Work and Pensions. Back

51   Private letter. Back


 
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