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“There are no bad regiments, only bad colonels” -Napoleon Bonaparte. And when the colonels don’t do their job, the whole organization quickly turns Rogue. Had Bad Can it Get?. A study of Safety Culture Abandoned Resulting in a Rogue Organization CAPE SMYTHE AIR SERVICE.

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“There are no bad regiments, only bad colonels” -Napoleon Bonaparte


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Presentation Transcript
had bad can it get
Had Bad Can it Get?

A study of Safety Culture Abandoned

Resulting in a Rogue Organization

CAPE SMYTHE AIR SERVICE

overview of systemic safety issues
Overview of Systemic Safety Issues
  • 15 accidents and incidents from 1996-2000

5 other operators in the same area averaged 1.8 accidents/incidents each during the same time period

  • 2 were mechanical
  • 13 pilot-induced (9 accidents, 4 incidents)
slide6
All accidents/incidents involving multiengine aircraft were flown by a single-pilot
  • 8 of the 9 PA-31 accidents/incidents occurred at coastal destinations
  • 8 of the 9 PA-31 accidents/incidents occurred during approach or landing
slide7
February 28, 2000

FAA flight Standards District Office

Anchorage, Alaska

Conducts

Office Safety Inspection Program (OSIP)

Issues OSIP Report

osip findings
OSIP Findings

Lack of Procedures

  • Company had no policy for assigning pilots to flights
  • Duty assignments were based on availability, not experience or training
  • Dispatchers used line-of-sight method to assign crews
osip findings9
OSIP Findings

Lack of Training

  • Training Manual met all regulatory requirements but failed to address the difficult flying conditions identified by Management
  • Training Manual and procedures not followed
  • Pilots receive IOE from assigned base of operations but received no local airport familiarization if reassigned to another location
osip findings10
OSIP Findings

Lack of Oversight

  • General Ops. Manual listed 5 people having Operational Control
  • 3 lived in Barrow, 2 lived in Nome, none were positioned at any of the other stations
  • Director of Operations and Chief Pilot were also line pilots flying up 120 hours per month, removing them from the operational control and oversight loop
  • Many stations had no oversight at all
what happens when you have a systemic failure to develop a safety culture
What happens when you have a systemic failure to develop a safety culture?
  • You have accidents
  • You have the same accidents,

over and over

And what do these accidents look like from the perspective of a safety culture so broken that that it becomes a Rogue organization?

slide12
In September of 2000, a Cape Smythe

PA-31T crashed during a gear-up landing into Nuiqsut, Alaska.

  • This was the Carrier’s 15th and final accident
  • 5 people were killed, 5 seriously injured
rogue pilot or rogue organization
Rogue Pilot or Rogue Organization?

It would be easy to blame a gear up landing on the pilot, after all, he acted alone right?

But this accidents collectively demonstrates all the failures of the organization to instill a robust safety culture.

The lack of safety culture failed to provide the pilot with the essential skills needed to prevent this accident.

root cause analysis
Root Cause Analysis
  • Conducted in-depth root cause analysis using TapRoot® root cause analysis software.
  • The company’s lack of system safety resulted in countless broken safeguards, dozens of casual factors and many root causes.
  • For the purpose of this exercise, I have culled a few of the casual factors and root causes to make my point.
  • This is not the complete study.