In response to Hugo Oscar Leimann Patt's question about legal consequences...
(Which in case anyone cannot remember it went something like this....)
"Now our challenge are the owners of the money. CEOs are reluctant, and we
don't have many arguments to convince them. In our last meeting I exposed
the legal consequences the security manager of Air-Inter suffered after its
A-320 crashed near Strasburg 1992 (negligent homicide for not have
installed GPWS in the planes). (see quote bellow) Now I'm looking for new
episodes. Perhaps ValueJet, or Air Ontario (after Dryden) etc. Please, if
any of you have some data to quote aboute legal consequences to managers
for negligent behavior, please mail me"
This is a really interesting area to us at the University of New South
Wales where one of our current projects involves training ab initio pilots
in CRM. As far as we know, there are very few institutions do this, but we
believe in the basic premise that IF CRM IS SO GOOD, WHY DO WE LEAVE IT
UNTIL PILOTS GET TO AIRLINES? (or indeed don't!). To answer this question,
we needed to look for really good metrics to assess the effectiveness of
CRM (the subject of many discussions on this group!) and so far we really
haven't found much that PROVES conclusively in a way that commands academic
integrity or indeed could easily persuade the non-believers of CRM that
they should be paying for training in this area. Our students don't get the
choice because we are all believers that CRM is a 'good thing' but even
then can we honestly say that our course content is correct other than by
sitting back for X years and see how our students do as pilots?
We asked industry how they measure the true success of CRM and the answers
can be a little depressing at times. As aviation is so safe, it is just
about impossible to measure in terms of accident clean-up rate (except if
you happen to be Al Diehl's A6 "81%" Interceptor squadron!) and in the
non-jeapordy world of CRM training where LOFT's cannot be failed, this
gives us few clues. We even asked a large international airline how they
continue to justify CRM training to their accountants in terms of results
(if I sound like a non-believer here it is because I dare to play devil's
advocate!!) or return on investment. The answer was "I remind them of their
duty of care. I ask them what they would say to the coroner if one of our
aircraft crashed and they were asked why they stopped doing CRM and all the
other major carriers continued". Should we really be resorting to negative
arguments and how does this help the small carriers who currently do not do
CRM? Surely we have the ability to collect the evidence to suggest to a
coroner (or whoever) that management would be negligent if they did not
start / continue CRM training?
I can't help getting the feeling that there is too much anecdotal evidence
floating around in our field which seems to support our assertions but
remain open to question. For example, I have attended CRM training courses
where the British Midland B737 accident at Kegworth in 1989 is used as an
example of poor CRM. As a negative example where trainees can say 'why
didn't the tech crew check what the flight attendants had seen etc.', it
seems to serve a purpose, but when I hear the point made that "...if the
crew had only practiced CRM" and then "...if the crew had only been trained
in CRM" then I start to get uneasy. I refuse to go pilot-bashing here and I
apologise to Captain Hunt for using him as an example here, but we have to
ask ourselves WOULD THE CREW HAVE ACTUALLY ACTED DIFFERENTLY IF THEY HAD
DONE CRM TRAINING? I am sure that all of us who have sat in on courses have
seen individuals who really don't want to take in the message - may be
these are the ones that always were and may still be accidents waiting to
happen? Just because crew records say that employee X has done CRM training
doesn't mean that they are trained and we need to know how to pick these
people out. It is easy to look at an accident with hindsight and say "if
the crew only applied the following CRM skills then it wouldn't have
happened" but in the real world...
If CRM is really as important as we all believe it to be then one day we
will have to start to grab the bull by the horns and start to pull out
those individuals who just don't get it! I would also suggest that ab
initio CRM is the place where this should happen. It is no good the big
carriers developing to the stage where they refuse to recruit 'CRM-unable'
individuals if these guys are going to go off and fly secondary level
airline of GA aircraft in the same sky. CRM is not a fix-all, but at the
same time it is really serious stuff and not a jolly outing in 'having a
nice time with your fellow crew'.
(I think I am going on a bit!)
Finally, I wanted to suggest an example of legal consequences for
management by going outside of aviation (which is something we can all
benefit from doing once in a while!). If you take a look at what happened
following the Herald of Free Enterprise disaster in 1987, airline
management might just get a scare. In case you don't remember it, the
accident occurred to a Roll-On Roll-Off ferry operated by Towsend Thoressen
(P&O) shipping as the ship left Zeebrugge with its bow doors open and
capsized with great loss of life. Although the initial cause appeared to be
crew error (the assistant bosum, whose responsibility it was to close the
door OR inform the bridge if they were not closed was asleep in his cabin),
the inquiry found rather more to the accident. The ship had a danger-side
failure system i.e. the bridge could not see the bow doors, had no
indicator light to say they were closed / open and had to rely on a single
individual (who as it turns out had been on an amazingly long shift and
fell asleep) to tell them if the doors were unsafe. The crux of the matter
is that the courts decided that it was the MANAGEMENT that were culpable
and as such could stand trial for CORPORATE MANSLAUGHTER. This was ground
breaking stuff in the UK and it was only a legal technicality that kept the
senior management out of jail for failing to assure a safe operating
environment. I was told by a reliable source that on news of the courts
decision to press corporate manslaughter charges, Lord King (BA) stormed
into the safety department and said MAKE SURE THAT NEVER HAPPENS TO ME!
Food for thought! (There is a good book all about this is anyone is
interested).
Right, I am going to shut up now....
Graham R. Braithwaite
Research Associate
Department of Aviation
University of New South Wales
Sydney 2052
Australia
Tel. + 61 (0) 2 9385 5756 (work)
Fax. + 61 (0) 2 9385 1072 (work)
Tel. + 61 (0) 2 9314 5061 (home)
e-mail: groovy_at_alpha.maths.unsw.edu.au
e-mail: G.R.Braithwaite1_at_lboro.ac.uk