Safety management is a clear and present danger. Why? And who can we blame?

10 August 2019 / by John Sarginson / GA in general, Governance, Opinion, Safety

The Fox accident: seven deaths, followed by an official crucifixion

We are human and we make mistakes. Mistakes cause accidents.

After any aircraft accident, we want to know why. But when there are no witnesses, no survivors, no proof of mechanical failure, recklessness, malice or external interference, the conclusion of an accident report should say: “We may never know what caused it.”

Accident investigators are ruthless and forensic; there are historical events, policies, procedures and safety systems to be scrutinised. A Safety Management System (SMS) may be found to have failed.  Remember, people dedicated to improving safety – paid or volunteers – are responsible for these systems.

So-called safety management is an increasing danger, because ‘system failure’ is the easiest place to find faults which raise blame-pointing fingers. They frequently point at those who are trying to prevent accidents. Safety has become dangerous because it may evict those who strive for safety, and replace them with more regulations.

These systems are complex, living things. They are continuously updated to meet changing regulations, local conditions, legislation and expectations. They can grow faster than humans are able to update themselves. Once upon a time, we would check the aircraft was safe to fly, then go flying; it was easy. Now we must also ensure that the paperwork will satisfy a court.

The law has become so complicated that even a pilot fresh out of a law exam can’t be guaranteed an active day in the air without unwittingly committing an offence. CAA prosecution lawyers are known to have asked defence rivals to help explain aviation law in court. Aviators across the board find it hard to keep pace with changing laws, rule parts, systems and expectations.

There is always greater value in seeking the cause of an accident and not finding it than in ‘closing the case’ via blame based on speculation. A wise man said that a bowl of speculation will not create a teaspoon of knowledge.

We – that is, GA and the regulator – jointly own these accidents. If we want to enjoy the benefits of a great industry, everyone must share the losses and costs. Yet when what caused an accident can’t be truly established, there is always those officials’ compulsion to place the blame on someone. They have to draw a line somewhere in the ashes, and move on… sometimes, to the next tragedy.

The Fox Glacier accident is no exception. Employing ‘system failure’, investigators have cast the blame on the owner-operator, company management, the pilot and the regulator.

To my knowledge, the owner-operator did not operate below an acceptable standard. If he did, it could not have been intentional. The operator should still be New Zealand’s most successful private helicopter operator. He should still be supported by the CAA, as he was before the accident. But he is being defamed, while we stand by and watch him crucified.

We think this could not happen to us.

We are wrong.

Who’s next for the chop?

These days, an admission of guilt in court may well be a pragmatic legal or financial necessity that does not reflect reality. So, when judging someone, be wary of courtroom outcomes. The current enforcement regime relies on people believing that where there is smoke, there is fire. Again, be cautious, because enforcement has been known to light the fire that created the smoke.

The management team for this operator apparently did nothing illegal. An honest, hard-working person simply started out one morning – like the owner-operator, armed with the Authority’s approval – proud of who he was and what he had achieved. Then came the shock: his efforts to prevent an accident had failed.

He found himself trapped in a whirlpool of personal and professional anguish, facing harrowing months of examination by the operatives of a harsh system – one which values a prosecution victory more than a lesson learnt. Then he was thrown under a bus.

The scenario is not unique. It makes no accident less preventable, but it makes room for more legislation. It is also a total waste of aviation expertise.

Contrary to claims, the pilot was fully trained, held the appropriate licences and was approved by the CAA as a competent and qualified aviator. At the time of the accident, was he breaking the law? If he was, did he do it knowingly? We cannot be certain. But if you believe in “innocent until proven guilty”, the answer must be “no”.

His logbook’s reportedly inaccurate pilot hour totals are minor and can be dismissed as an oversight. The fact is that this pilot had more hours than most, and more than enough. Claims that he did not check weight and balance and was overweight by 65kg (in a more than 2.25-tonne all-up weight helicopter) could only be proved if he had survived.

And to suggest that the pilot could have had more training is an oxymoron. Young or old, life’s a learning curve and we all benefit from more education.

As for the mountain flying ‘issue’, virtually all aviation in New Zealand involves mountain-related flying and no part of it is more or less challenging than another. Three mountain training flights in my backyard ended with the loss of eight pilots, and none were at significant altitude or over a glacier. The pilot in command of that fatal Fox flight was experienced in mountain flying in local conditions.

None of the unfavourable claims against the pilot bear close scrutiny as having caused the crash, and speculatively laying blame on someone who cannot defend himself is as low as it gets.

Those involved in this tragedy were skilled, talented and dedicated to aviation and good airmanship; they were not the shysters you might perceive them to be from the report.

Note this:  ‘in the interest of aviation safety’, the Authority has the power to strip privileges from anyone it assesses as possibly culpable for an incident, or being bodily unfit or mentally ill, and it has acted in this way on the flimsiest of evidence, sometimes before a fair hearing in court and before a person was charged.  This is a Napoleonic reversal of the ancient principle of habeus corpus. It is applied by the CAA to anyone under its suspicion, involving anything from a heart murmur to the claims of an ex-partner that her airline pilot lover is insane, or an accident, and it sends out this message: “You are guilty or unfit until you prove your innocence or good health, at your expense”. Proving yourself not guilty is made harder when those who, sub judice, would normally be bound to presume you innocent or in fine fitness have inferred that you are not.

Forewarned of what lay in the Fox accident report, the CAA issued a pre-emptive statement insinuating that its auditors could have done more to make the operator compliant (simultaneously throwing its own personnel under the bus as well).

The fact is, everyone can always do more. What the CAA did not tell the public was that it had a fraudster on the Fox audit team. It is seriously wrong when operators strive to meet higher standards while the regulator falls short of being fully open and transparent.

For decades, some in New Zealand aviation have suffered at the hands of corrupt CAA personnel, while others have prospered from them. The Fox operator suffered.

Question to CAA Director Graeme Harris: It’s all very well to blame your staff, but where does the buck stop?

The CAA said that its auditors failed to act on past findings identified during the investigation. This is disingenuous, shows borderline disloyalty to staff and is an admission of a broken directorship.

If the auditors had closed the operator down due to “woefully inadequate oversights”, they could also have shut 90% of all other operators’ hangar doors. (The other 10% were lucky, or just starting out.) The reason is that there are enough discretionary aviation regulations to discredit anyone at any time. I challenge anyone to prove otherwise.

A regulator operating with genuine transparency and honesty would have to admit that the industry – not the CAA – is why these accidents are so rare. We have come a long way in just a few decades of providing helicopter scenic flights to many millions who want to experience our amazing landscape.

It is time for GA and the CAA to stop talking about working together and start doing it. Repetitive CAA claims that “we are no longer failing” no longer cut it. We need proof of positive actions and accountability. To date, we have witnessed unwise actions, horrendous cost increases, over-reliance on regulations – and little accountability.

We need to jointly share this cluster of stuff-ups and corruption and build the backbone to fix it. No loss of life is acceptable, so let’s learn from the likes of an operator who helped pioneer aviation tourism, not destroy him over something no one can fully explain.

This is not just about the regulator. If we and the CAA can’t sort it out, in an authentic partnership, all will suffer.

Flying in New Zealand is safe, in spite of general aviation’s rapid growth and its challenging operating environment. Our aircraft reliability is excellent, thanks to great maintenance providers who suffer much more from over-zealous enforcement than accident investigations.

If we want to see a continued increase in flights and fewer accidents, GA and regulator must work as a team – not work against each other.

  • John Sarginson has spent his life close to aviation. He says: ‘I have had good times in the sky and bad times in court, so I know both sides. Too often, I see hard-working people dedicated to aviation being wrongfully defamed following accidents and allegations.’