Dirty secrets

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© Civil Aviation Safety Authority

Beware the mudguard organisation: shiny on top, but filthy underneath

The airline began operations in 1993 with just one aircraft. The following year, when its shares went public, there were fifteen. The year after that there were 50 somewhat elderly DC-9s (and a few newer MD-80s) bearing the logo of Valujet which had made a $US21 million profit in the first year. Some of the start-up airline’s other statistics were equally memorable: over the three years from 1994–1996 it made 129 unscheduled landings and its accident rate was 14 times that of the established airlines.

Then, in May 1996, Valujet flight 592, a DC-9 flying from Miami to Atlanta crashed into the Florida Everglades, killing all 110 on board. Used oxygen generators illegally stowed in the cargo hold without their safety caps on had caught fire. They had been placed there by a maintenance subcontractor despite federal regulations forbidding such hazardous cargo. The description on the cardboard box holding the canisters had been ‘company material’.

Pilot and writer William Langewiesche came to a scathing conclusion: ‘ValuJet Flight 592 burned and crashed not because the airplane failed but, in large part, because the airline did.’

Valujet was the model of a mudguard organisation. Like a road wheel cover on a vehicle, it was superficially impressive but dirty beneath its polished surface. Valujet was also somewhat less than the sum of its parts. A so-called virtual airline it contracted out many back office services, such as catering and maintenance. These were carried out by the lowest bidder with penalties imposed, according to contemporary media reports, for late return of aircraft to service. Here was a structure and a culture riddled with dysfunctional and dangerous characteristics.

There have been notorious ‘mudguards’ in Australian aviation, too. On 2 October 1994, a Seaview Air Aero Commander 690 flying from Williamtown, NSW, to Lord Howe Island crashed killing all nine people on board. The Commission of Inquiry into the accident stated that Seaview Air was ‘a slipshod, often wilfully non-compliant organisation in which breaches of regulations and unacceptable practices were … commonplace’.

On the day of the crash, the twin-engine turbo-prop aircraft was 220 kg overweight; the pilot was not validly licensed to fly the aircraft; the aircraft had not been properly serviced according to regular maintenance schedules; the company was operating as regular public transport but was only approved for charter work; the right engine of the plane had exceeded a 5400-hour manufacturer’s limit; during the last 12 months, numerous defects had not been recorded; and the life rafts were inaccessible. The culture that had developed in Seaview Air was, according to the Commissioner’s report, an ‘uncaring attitude of a greedy operator which threw caution to the wind without considering the consequences of putting lives at very real risk’.

The Commissioner’s report also took aim at ‘an incompetent and timid regulator’. Like Seaview, the Civil Aviation Authority, (which was dissolved and reformed as CASA and Airservices Australia) was not as impressive in performance as in appearance. The CAA failed to look closely at the operator which had been named in Federal Parliament as a safety risk.

There are at least seven identifiable characteristics of a mudguard organisation, although not all are required to produce a ‘filthy’ workplace. Do any of these signs ring a bell with you? If so, it’s time to take stock.

Low employee morale: Hands up. Have you ever called in ‘sick’ just because you didn’t want to go in to the office? Where there is low morale in a company, employees regularly call in sick, leave early, don’t complete their duties and have bad attitudes to work, so it is difficult to create a healthy and productive working environment.

Lack of career growth: Do you want to keep advancing your career but when you look around your workplace there is no encouragement or opportunities to do this? There is no training available and even after several conversations with HR about growth opportunities, nothing happens? And is your pay lower than desired and a pay rise only in your dreams?

Lack of compliance: The helicopter operator that ignores procedures in the flight manual because ‘that’s not how we operate here’; the maintenance organisation where you’re told to ‘just get on with it,’ in the absence of maintenance documents. These are danger signs.

High turnover: Are people at your organisation constantly leaving? Your desk mate changes before you ever really learn their name? Workplaces that have a toxic environment tend to have a high revolving door for employees. Why hang around if you are being mistreated or the conditions are not what you signed up to?

Poor communication: Do you often feel left out of the loop regarding important information? Do you get little or no feedback on your performance or when you do, it’s negative and not constructive? Or when you do something great does your boss take all the credit? A lack of communication characterises most toxic workplaces and can lead to increased stress levels, negative attitudes, and feelings like you are working in a vortex never really understanding what is happening.

High stress: Employees who work in a stressful environment will find that it can interfere with their productivity and performance and can impact their physical and emotional health. You tend to get sick more often, sustain more injuries, lose confidence and have higher levels of fatigue and depression than people who work in calmer workplaces. The maintenance contractor that Valujet hired, SabreTech, was according to Langewiesche, ‘… inhabited by a world of boss men and sudden firings, with few protections or guarantees for the future. As the ValuJet deadline approached, they worked in shifts, day and night, and sometimes through the weekend as well.’ This would have been a very high-stress environment to work in.

Dysfunctional: Is there always an office drama? Are you anxious that colleagues are talking behind your back? And do meetings feel like a waste of time inevitably leading to chaos where nothing is achieved? If you work at a place where there are always rumours and gossip, there is misunderstandings, favouritism and infighting, and management are constantly washing their hands of the problems?

‘Every accident, no matter how minor, is a failure of the organisation,’ said Kenneth Andrews of the Harvard Graduate School of Business Administration in 1953 and ‘is a reflection on management’s ability to manage, except for act of God. Accident prevention is a management function. Even minor incidents are symptoms of management incompetence that may result in a major loss.’

Clean up or clear out: what you can do

The link between workplace stress and poorer safety is both intuitively obvious and well established in occupational health and safety research. In short, stress and fatigue are the parents of error. Aviation adds another layer of danger: work such as maintenance and ground handling can be not only dangerous in itself, but mistakes made here can add to the risks of flight.

An important point about mudguard organisations is that they do not necessarily reflect personal stupidity, arrogance or a dismissive attitude to safety. No-one, even in the most dysfunctional organisation wishes for an accident, or is unaffected if one happens. The problem is more deep-rooted than one so-called bad apple. Systems themselves can go off track, seemingly out of human control. Writing about Valujet 592 Langewiesche says, ‘The two unfortunate mechanics who signed off on the non-existent safety caps just happened to be the slowest to slip away when the supervisors needed signatures.’

The good news is that if you find yourself on the dirty side of the mudguard, you have options. Walking away is only one of these options, and should be a last resort. It may remove you from the problem, but it doesn’t fix it.

There are resources available to repair and maintain organisations. And the time to take advantage of these is before an organisation turns sour. Part of the role of CASA’s aviation safety advisors (ASAs) is to make ‘house calls’ on aviation organisations. They can advise on organisational leadership, safety resources, and practical steps to build a safety culture. ‘We don’t judge. We just want to help,’ says ASA team leader Alf Jonas. He emphasises that an organisation does not need to be ‘at death’s door’ to qualify for a check-up. ‘A check-up is always a good idea, even if you seem healthy. It’s never wasted time,’ he says.

CASA’s Safety Behaviours: Human Factors for Engineers resources kit has two videos that are valuable watching. The first case study, Crossed Wires, paints a short, but according to many viewers in the aviation industry, compelling picture of an out-of-control organisation. The second video, The Right Connections, shows but does not preach the solutions: a renewed emphasis on order and procedure, initiated in the most basic activities of the organisation, and reinforced by example from the very top.

Further information

Carillo, R. A. (2004). Breaking the Cycle of Mistrust to Build a Positive Safety Culture.

Langewiesche, W, ‘The Lessons of ValuJet 592’, The Atlantic, March 1998.

Lauriski, D. (2016, April 28). Seven Characteristics of a Positive Safety Culture — Predictive Safety.

Staunton, J. H. (1996). Report of the Commissioner/Commission of Inquiry into the Relations between the CAA and Seaview Air, Canberra: Australian Government Publishing Service.

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4 COMMENTS

  1. Certainly some good reminders of failings that occurred in spite of supposed oversight by very expensive regulators.
    In Australia did the change from CAA to CASA make any difference? Many if not most industry personnel would be hard pressed to discern the difference although judging by the Colmar Brunton report, the report commissioned by CASA to gauge industry satisfaction with CASA, things have not improved. In so far as the administration of General Aviation (GA) is concerned, hampered as it is with the most convoluted and unworkable rules framed largely as criminal offenses of strict liability, in CASA Chairman Jeff Boyd’s own words “its a mess” (Tamworth 2016).
    It’s become obvious that CASA, an independent Commonwealth Corporate body, has no appetite whatever for meaningfull reform, reforms like medical standards for private pilots as in the USA , in spite of CEO Shane Carmody stated objective to administer on the basis of “evidence” (Avalon 2017).
    Sadly, saddled with such unworkable and unfair rules, coupled with fee gouging (e.g. $8000 upfront for a flying school permit, a permission to teach not required in the US) for all sorts of previously unheard of permissions, not to mention $283 biennial ASICs (special ID) with no relief for commercial pilots, instructors or the elderly, GA has suffered serious decline.
    Loss of hundreds of flying schools, lack of recency, high costs of fuel and maintenance, all symptoms of low throughput and lack of competition, has created general stress levels exactly as decried in this article in addition to loss of services and employment.

  2. Agree whole heartedly Sandy. The saddest thing though is that our regulator simply haven’t got a clue as to what’s really happening out there. Keeping the rules & regs at a level that they themselves have little idea about never lone the aviation Co’s trying to make a living in a convoluted industry. Jobs for the boys, power trips & no doubt some level of corruption which is almost a way of life in big business these days in Australia inc Govt’s is now so entrenched that our GA industry is all but dead at a commercial level & declining rapidly in the private sector.
    Australia the wealthiest third world country!

    The ‘Mudguard’ picture is a good one, it’s rife right here in Australia as well.

    As is well known in our corrupt industry “Safe skies are empty skies”!

    RIP Australian GA, was a really exciting area once upon a time:–(

  3. I agree with both of the previous comments with one I would like to add is that there are operations that are so obviously in breach of all kinds of regs and just basic common sense but these are allowed to continue . CASA seems so preoccupied with the paperwork but they are blinded to the blatantly obvious in the plainly visible .
    The situation with the person who has been recently arrested with umpteen( Hundreds ) charges laid but years of dillydallying has continued when general knowledge was out there with discussion openly happening in normal conversation
    Some of the operators in both the Airline and GA and those that consider themselves somewhere in between are still blatantly flouting the law and putting people at risk .
    CASA certainly needs a serious shakeup not just another name change

  4. It is easy to be a “CASA -basha”, unfortunately the allegations you guys make can be seen if interpreted that way, but like everything else in life I suggest that there are external influences bearing on unconnected elements of Ozzy aviation that conclude in a nexus of negativity, just like after a major hull loss there is always a plethora of unconnected elements that are seen to have conspired in the end to make a black hole scenario.

    This does not excuse cultural cringe at the regulator, the “institutionalised timidity” or the inference that it is intelligent to avoid conflict with “powerful entity” challenges. (I cannot see much difference between say CASA with other “government” establishments – say ASIC for that matter)
    One such element of contributing factors pressuring this regulator is one that I perceive sitting behind such evidence against the regulator comes from the veiled threats or pressures of various “political masters” and the apparent Senior P.S inputs. I perceive that it is like an unidentified passenger telling the PIC what to do next during flight.
    My two bobs worth to Shane Carmody would be to prevent all weasels and stoats from being able to take over the wheel house from time to time..

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