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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
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
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)
9 of the 13 accidents/incidents involved PA-31aircraft
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
February 28, 2000 FAA flight Standards District Office Anchorage, Alaska Conducts Office Safety Inspection Program (OSIP) Issues OSIP Report
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 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 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? • 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?
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? 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 • 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.
