Flight safety hits turbulence

Police at the scene of the Kaiaua crash where the pilot and instructor died practising for a Warbirds aerobatic display. Picture / Kenny Rodger.

Corporate culture often plays a role in accidents, said Kevin Ward when he was director of Civil Aviation. Ward has gone from the role, but his comment rings true among those aviators who believe a lax safety attitude emerged after the Government stepped back from direct enforcement of standards in the early 1990s.

A "cowboy culture", is how one lifetime flyer put it.

Shared values influence behaviour, Ward said in his 1997 article about corporate culture. His intention was to challenge aviation companies to ensure their culture promoted safety. He gave the salutary example of a crash in Canada in which which six passengers were killed. The company involved had a lax safety culture.

The Civil Aviation Authority's own culture is being debated after criticism by a coroner who ruled on a case which mirrors the Canadian example.

CAA continued to let Michael Bannerman fly despite many rule breaches and overt warnings from fellow pilots, one predicting a fatal crash. Bannerman's plane crashed in fog short of Christchurch airport in June 2003, killing him and seven passengers.

The Transport Accident Investigation Commission (TAIC) and coroners have listed CAA's failure to react adequately to indicators of unsafe practices as being among the causes of other fatal accidents.

To some this is evidence of a CAA culture that is weak on safety. CAA's culpability, they say, is its failure to clearly mark and enforce boundaries.

Pilots by nature are risk-takers, says John (who did not want his surname published) a lifetime pilot now retired. Most are sensible enough to curb any tendency to compromise safety but some need big brother standing over them.

"There's always been idiots in aviation," he says, "but they had been kept in check by the experienced ones, the hard boot of [officialdom] who would say 'watch out or we will put an incident notice on you'.

Nowadays everyone wants to fly like the Warbirds."

By experienced ones, he means the flight-testing officers the Transport Ministry used to employ, says John, "who could isolate themselves from these sort of instances". Now the industry polices itself, with CAA doing the monitoring.

CAA does not accept responsibility for safety per se. The industry is responsible for safety and the CAA is responsible for monitoring that process, John Lanham, CAA's head of general aviation, is quoted as saying in the Bannerman coroner's report.

For the likes of John the pilot and Bernie Lewis, who has a long international career as a test pilot, CAA needs to be more hands-on, having become "too involved in getting all the paperwork correct".

A revolution in the way aviation is regulated began in the early 1990s. It had been regulated by the Ministry of Transport, a huge bureaucracy responsible for functions as diverse as air traffic control, road safety and inspecting lifts. Restructuring saw it peel off most functions.

Traffic became the responsibility of the police, air traffic control was assigned to a state-owned enterprise, the Airways Corporation, and the task of regulating transport safety went to new entities such as CAA, the Maritime Transport Authority, Land Transport Safety Authority, with TAIC investigating accidents with public safety consequences.

The rationale was that all involved had a role to play in safety. It also had the effect of shifting responsibility for aviation safety from the Government to monitoring organisations. Erebus, 1979, was not too far in the past and a desire not to be the body held responsible for such a disaster may have been an impetus.

The CAA set about writing new regulations, and 15 years on that is nearly complete. During the 1990s it concentrated on setting out "the rules of the road" for big airlines, then for the smaller aircraft of the general aviation sector. Nothing was left untouched. New business, management and assessment systems were introduced. In 2000 the CAA itself underwent an internal restructure into units focusing on airlines, general aviation, professional licensing and government relations.

Such fundamental change drew opposition and, says Lanham, most of the industry was against what for New Zealand was a leap into the unknown.

Ward, who introduced the changes, copped the brunt of dissatisfaction but, as one former CAA staffer put it, "he was unpopular from the moment he breathed because he was not an aviator".

Ward changed the face of the industry and should share credit for the improved accident rate of recent years, says the staffer. "To say the old way of the Government looking over your shoulder was better is just bollocks.

"I can remember going to a public inquiry into a crash where a pilot had put nine people into a six-seat plane and crashed it ... you have got to remember that Erebus took place under the old regime."

The over-arching regulatory system is fine but there is always room for improvement. Could the CAA have grounded Bannerman? In the four years before the accident Bannerman's company Air Adventures had 39 findings against it, and had four times been classified by CAA as high-risk. Coroner Richard McIlrea noted that had the CAA enforced regulations that flight would not have got off the ground.

So where was the CAA? Checking the paperwork, say critics. "They were intent on getting the Is dotted and Ts crossed," says Lewis, who had a long and respected career as an international test pilot. "When the inspectors went out they looked at the manuals. There was no hands-on stuff."

Lewis relates an experience from 1998, before the appointment of current CAA boss John Jones under whom Lewis believes there has been improvement, of being asked to test-fly a kitset helicopter. The owner had it checked by a certified aeronautical engineer and the CAA had approved it. "I went out to test-fly it, checked the controls on the ground and they were connected up opposite. If I'd taken off I would have crashed within a matter of seconds."

Statistics compiled by CAA show airlines flying bigger planes are meeting safety goals but commercial operators using small planes, agricultural operations and sport flying are not.

It is easier, however, for big operators such as Air New Zealand and Qantas to comply under the present system, a senior international pilot says.

They have the money, skills and quality assurance programmes to maintain standards, whereas a sole-operator, such as Bannerman, may have to make a choice whether to defer maintenance in order to make a payment on the hefty mortgage taken on to buy the expensive but aging aeroplane their business depends on.

"They are pressed into a corner where [some] will unfortunately take risks with people's lives when they haven't been closely monitored and properly controlled," says the pilot, who has experience in many areas of New Zealand aviation. "It's always going to be too late when you start by investigating the crash site."

That view was shared by TAIC which examined a 1997 crash which killed pilot Timothy Thompson, 27. He was on a night freight run which crashed into the Tararua Ranges. It was thought severe icing resulted in a loss of control and that his mental functioning may have been impaired by carbon monoxide leaking from a faulty heater. But TAIC considered a "deficient safety culture" by the aeroplane's operator, United Airlines, and CAA's "apparent failure" to take appropriate action had contributed.

The CAA had noted repeated major failures to comply, ranging from pilot training to maintenance, that indicated an unsafe culture and should have meant United Aviation had "forfeited its right to participate in the aviation industry".

That struck a chord with Thompson's parents. While sorting out their son's affairs they found he had kept a computer record detailing his concerns about safety which included a lack of spare parts, no maintenance controller, and inadequate communication between engineering staff.

His father, Mark, believed his son had become sufficiently disillusioned about the unsafe culture to have begun sending out letters in search of a new employer.

TAIC's criticism sparked a Government inquiry into the performance of the CAA, a government agency, which served to soften TAIC's blow, concluding that the aviation framework was sound although improvements could be made to monitoring procedures.

Bill Jeffries, a former cabinet minister who at the time was TAIC's chief commissioner, attacked the ministerial inquiry which he said left unanswered the central issue that had to be confronted by Civil Aviation: "What steps should the authority take and how quickly should it take them when it finds out an airline is being run dangerously?"

Jones, a former Mt Cook Airlines pilot with four decades in aviation, has a supporter in opposition aviation spokesman Maurice Williamson, and from people such as Lewis who are keen to have a pilot back in the driver's seat.

Jones took the job a month after September 11, a time he suggests when relations between the CAA and the industry were probably at their lowest point and with a mountain of unpopular work to be done - more than 600 operators to be re-certified, new rules to be completed, new surveillance and intervention processes to be bedded in.

"Ground zero" is how he describes it. "I took the job because I thought I could make a difference. Six years later, the results show I have."

The industry has grown - a third more licensed aviation business operators, 20 per cent more registered planes and 9 per cent more licensed pilots, maintenance engineers and air traffic controllers. And the skies have never been safer: a 39 per cent reduction in accidents for every 100,000 flying hours in the general aviation category.

Another fatal crash under Jones' watch killed the pilot and instructor during practise for a Warbirds aerobatic display. The flight which killed Olympic yachting gold medallist Chris Timms, 56, and Ardmore Airport chief executive Kerry Campbell, 57, and endangered the town of Kaiaua, southeast of Auckland breached many rules.

The manoeuvres weren't authorised, were in an illegal area and at an illegal height, and the instructor wasn't qualified for the task.

The CAA found that by assigning an instructor without the appropriate qualifications the Warbirds Association broke its own rules. There was no fine or censure. The CAA recommended Warbirds "strengthen their exposition to reflect greater control" over private owners and operators.

Jones acknowledges "we could have done more to prevent [the Bannerman] crash" but says he's not fazed by calls for his resignation. "I'm a mountain pilot. You don't bail out on your passengers and crew when the going gets tough."

Cracking down

Action taken by the Civil Aviation Authority

Individuals

1996: 1 licence revoked
1997: 2 licences revoked
1998: 1 licence revoked
1999: 5 licences revoked
2000: 1 licence revoked
2001: 2 licences revoked; 2 licences suspended with re-examination of holder required before reinstatement.
2002: 1 licence revoked; 1 licence suspended and conditions applied
2005: 2 licences revoked; 1 licence suspended with re-examination of holder required before reinstatement

Organisations

1996: 1 certificate suspended and conditions applied
1997: 2 certificates revoked; 1 certificate suspended and conditions applied
1999: 1 certificate revoked
2001: 1 certificate revoked
2002: 1 certificate suspended and conditions applied
2005: 1 certificate revoked