“… the failure (both the air carrier’s and CAA’s) to take every measure to reduce a known collision exposure.”
Civil Aeronautics Board (CAB)
The scene was not only spreading sorrow and uncertainty wherein tears, sobbing, and people all over were looking for a clue in this accident. Over all these years, I remember the day I was about to tell this safety-fade-away-based story to my kid, who is attending a commercial pilot course now. Love and passion lies in every cockpit, parents relay aviation to their sons and daughters, friends treasure hangar anecdotes within their lives, as well as stories and secrets for as long as they live, they deem their selves as band of brothers, and these are nice and tender factors and a romantic view for aviation to be shared next to a cup of coffee at some flying club lounge or restaurant, but what happens when there is an accident and death toll marks our lives forever? What can be told about it? I would tell then safety is not romantic.
We all agree safety is a perception and state, but it lies on actual events due to the risk management process, on real budgets based on the safety policy, and an accident will occur when latent failures are able to tear down all defenses, and it does not matter we are talking about here our kids rendering unsafe services in the cockpit, or our parents working at the hangar or the ATC with fatigue or without the required training. We have to acknowledge that with these latent conditions we are digging deep inside the protection system, and an accident will probably occur. An accident is not a matter of bad luck, because when we talk about safety, we are managing real risks and this is not romantic at all.
Witnessing all of that above, I agree with Tony Tyler, former IATA’s CEO and Director, who in 2014 said “every accident is one too many”. That is why I decided to share now some notes of an audit report I wrote more than fifteen years ago. After reading all of the items below I could say any matching is just a pure coincidence.
Maintenance Organization
- Statement of compliance not aligned to current State’s regulations.
- Continuing Analysis and Surveillance System meetings not performed, but documented as done.
- Capabilities decreased, but not updated.
- No Safety Manager assigned for more than three months and PMI was not advised about it.
- Job cards not performed, but recorded as done.
- No analysis performed on which maintenance jobs are critical.
- MEL items not recorded on log book sheets. Just “internal” recording used.
- Training performed by uncertified instructors and performed not according to a schedule or as required by pertinent regulations.
- Wages unpaid as agreed with staff.
- When log book maintenance entries were not convenient, sheets were reprinted and new entries were done again.
Airline
- No documented interaction link with the Maintenance Organization.
- No technical representative assigned for critical maintenance tasks.
- Safety Manager not assigned and POI was not advised.
- No safety drills executed.
- Safety Risk process not performed.
- Safety investigations not performed as documented.
- Safety audits not performed as documented.
Are we talking about causes of an aviation accident here? That is why I remembered reading the publication “Improving the Continued Airworthiness of Civil Aircraft: A Strategy for the FAA’s Aircraft Certification Service, Chapter 3: Causes of Incidents and Accidents” that said “the definition of cause given (…) takes into account the many events involved in an accident or incident. These events can be viewed as links in a chain. Investigations of some hull loss accidents in the United States have revealed as many as 20 links in the chain; the average is just under 4 links. For example, after an exhaustive technical and legal investigation into one controlled flight into terrain (CFIT) accident, an official commission concluded that at least 10 essential cause factors were involved. If any one of these 10 cause factors had not been present, or if some of the factors had occurred in a different order, the accident would not have happened. The most effective accident prevention strategy must take into account all the links in the chain of events that lead to incidents and accidents.”
After writing my audit report, nothing happened. “Changes are not possible, Sergio”, my boss told me. Then I understood what reality means. I am also aviation romantic. I am proud to be an aviation inheritor. What aviation could I inherit to my kids? If the airline decided not to fix all of the above, an accident will occur, because safety is not romantic!
