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Wednesday, August 1, 2007

Safety Update: Hang 'Em High

IT IS A FREQUENT COMPLAINT ABOUT HELICOPTER accidents. The pilot may have screwed up, caused the aircraft to crash, maybe even people to die. But what if management action or inaction put him that pickle?

What if management wouldn’t take an aircraft out of service for use on training flights, for instance, and pilots didn’t get time to practice instrument skills? What if a company preaches sound aeronautical decision-making, but doesn’t pay pilots to drill in those skills? If such things are the case, you might ask, why not hold the responsible manager accountable for those actions? If they lead to a fatal crash, for instance, why not bring the manager up on criminal charges of manslaughter?

That’s not an outlandish question. You’ll hear it from a relative or acquaintance unfamiliar with aviation, particularly af-ter a crash. Because it is on the public’s mind, politicians are wont to seize and make hay with it, or headlines. Sometimes that triggers international incidents.

Take the case of the two U.S. pilots of an Embraer Legacy 600 that collided midair over Brazil’s Amazon with a Boeing 737, killing all 154 on board the airliner. The pilots were detained for months in Brazil, despite clear evidence that controllers had put the aircraft on a collision course. They face charges in a Brazilian court this month.

There is the more recent case of a Mil Mi-8 that crashed on a short flight in Sierra Leone, killing 22 people, most from the neighboring nation of Togo. Sierra Leone officials arrested their own transport minister and civil aviation director and their top deputies on suspicion of bribery in regards to the crash. Last month, they arrested two Russian executives of the operator, Paramount Airlines.

The Brazilian case got the attention of the U.S. government and international aviation groups, like the Flight Safety Foundation, that argued Brazil was out of line in prematurely taking criminal prosecution action in what was an aviation safety matter. The Mi-8 crash got the attention of Togo’s government, which declared a national day of mourning, and of Moscow, which dispatched diplomats to the West Africa nation.

The question of criminal prosecution after aviation accidents is controversial because locking up "wrongdoers" would wipe out the foundation of the aviation accident investigation process.

That process, at its heart, is cooperative. It is based on the assumption that all the key players in an operation that has suffered an accident will share their knowledge of the events related to the crash. Their cooperation is secured through the agreement that the probe’s goal is to make flying safer, not to pin blame on individuals.

Criminal investigations are adversarial. They assume a crime was committed and the guilty party will work to conceal information from investigators. Everyone’s a suspect. The goal is to punish the wrongdoer as harshly as necessary. Faced with that prospect, anyone involved in such a probe who isn’t an investigator or lawyer is wise to volunteer nothing. At least, that’s what a criminal lawyer likely would advise.

So when you ask, "Why not just lock up" the director of ops or another top manager, you provoke the counter-question: "What is more important to you, justice (or vengeance) or improved safety?"

The argument that the trade-off is justice vs. safety has several critical assumptions. The first is that investigators possess information against which the statements of those involved in the operation can be weighed. This moves a probe beyond "A said/B said." It also allows investigators to prompt players to give, shall we say, a more full and frank account of events related to a crash.

The second is that the probe is thorough. To fully support it, all participants must believe it will get to the root of the cause and not stop with a convenient scapegoat.

The third is that all concerned are confident those running the investigation are knowledgeable, at least about rotorcraft in general and at best, about the specific aircraft type and operation involved.

Lastly, for an investigation to be an effective collaboration, all concerned must believe the probe is unbiased.

These four points are where investigations of helicopter accidents in particular breakdown. When people in aviation say, "Hang ’em high," they’re not expressing ignorance of safety investigation philosophy; they’re venting frustration with its failure in practice.

The fact is that too often helicopter investigation findings aren’t based on good data, thorough processes, knowledgeable insight, and unbiased work. Data collection commonly is cursory. The International Helicopter Safety Team reflected this when its analysis team, which attempted to set the foundation for pursuing an 80-percent reduction in helicopter accident rates in 10 years, urged the U.S. National Transportation Safety Board to be more active in helicopter investigations. Arguably, the world’s premier aviation accident agency, the NTSB doesn’t send investigators to most helicopter accidents. Instead, it relies on reports from FAA field inspectors or other in determining the cause of an accident.

That logically makes it difficult to conduct a thorough investigation, have great insight into what happened, or en-sure impartiality. Until that is fixed, efforts to improve helicopter safety will work in the shadow of the gallows.

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