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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