Re: Corporate Manslaughter and so on...
cxcrm_at_cxair.com
Fri, 20 Jun 1997 11:28:14 -0700
Graham Braithwaite wrote:
>
> G'Day CRM Developers!
>
> 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.ukGraeme, what about the Aero Commander, Lord howe Is. BASI report.
Regards Julian Hipwell