Testimony of Major Andrew Sayers

Pilot Incapacitation: the human factor

At one level this is a Report about pilot incapacitation. In accident scenarios the main focus is on aircrew decision-making where more immediate causation is examined.

After an occurrence reports and investigations are submitted to authorities and recommendations are made with a view to prevention of further accidents.

This Case Study includes decision-making that took place (and is currently taking place) far removed from the occurrence in time.

They include political, policy-making decisions, organizational ones and the role, as well as the personal dynamics of the pilot concerned, leading up to the occurrence. The Reporting system and feedback is also examined.

 

The pilot in this case has been found to be without blame or culpability.

The other levels that have been included in this report, written from a systems perspective demonstrate how the context, the system within which a pilot works, impacts on him.

This knowledge comes as no surprise to those who remember the Mt. Erebus disaster. More importantly it demonstrates how potential learning about systemic failures can be lost; what is surprising is that the 'system' has not been able to capture important information in order to prevent further accidents.

The causal chain in this occurrence is multifactorial and may have roots in policy. It starts when he was boarding his aircraft and was splashed with organophosphates. The liquid dripped off his clothes and onto the aircraft floor.

This chemical should not be mixed with aluminium. It set up a chemical reaction and the gas so formed began to effect the pilot. He became incapacitated during flight and lapsed in and out of consciousness. He activated the autopilot but was conscious enough to land successfully.

He was left, coughing and vomiting for nearly an hour, unattended. By the time medical assistance was sought he was seriously ill and close to death by the time he reached hospital.

Organizationally there were significant management failures:

- The pilot drew attention to the inappropriate use of FAM30. He had a duty of care and fulfilled it. His concerns were dismissed.

- Safety Regulation Group letter of 23rd March 2001 drew attention of Owners/Operators to risks - "advice should be sought in every case, regarding the use of specified disinfecting agents and their potential for harming aircraft materials….disinfecting agents need to be washed off as soon as possible once they have achieved their intended purpose." (18/49)

- COSHH regulations were ignored by the company at the time of the accident

- No risk assessment prior to occurrence

- Company purchasing procedures were faulty enabling them to bypass correct procedures (ref CEO letter)

- Failure to act on instructions written on the container regarding toxicity.

- Incorrect solution of FAM30

Knowing this was the case there was:

- no safety equipment
- no First Aid
- The diagnosis was chemical bronchiolitis
- He is disabled but may improve

They dismissed the pilot who was now unable to fly in single-pilot operations.

This led to an Employment Tribunal that found that the dismissal was unfair. However it was won by the airline on appeal. This despite court observations that held that:

 

There were repeated failures to obey court orders to supply documentation.

  In its observations on the evidence the court noted:
 
Organizationally the communications were scant
disappointing
unsatisfactory
unwilling witness
minimal recall by CEO
withholding the information
disinterested (or not interested?)
was not genuine
making excuses
untruthful
unlikely claims
unreasonable employer
lacking in consultation
non-compliance with safety regulations

    
This case is relevant to systems safety because it demonstrates many of the hidden decision-making processes that contribute to accidents. These latent errors are to be found in the various layers that make up the safety system. They can be seen in the outworking of decision-making – morbidity in pilot health.
 
What it reveals is an attitude to aircrew that gives the pilot legal responsibilities and obligations for incidents and accidents while the decision-making that incubates latent errors are left, in the main, untouched.

Human factors are important to aviation safety because they can uncover latent errors and thus avoid future accidents.

The court processes and litigation in this case have allowed the systems safety failures to avoid any serious systemic attempt at rectification.