The Seaview disaster: conscience, culture and complicity

    20349
    Artwork © CASA

    Adrian Park reflects on the grim but important lessons from a watershed crash that happened 20 years ago

    A little after midday, on Sunday 2 October 1994, an Aero Commander 690 operated by Seaview Air taxied for take-off from Williamtown, NSW, on a flight to Lord Howe Island. Eight passengers, including honeymooners and a family with two children, boarded the single-pilot aircraft. Unknown to the passengers, the pilot’s conscience, and the culture within which it breathed, had sealed their fate.

    Half an hour later the 25-year-old pilot made a call on the company’s internal communications frequency: ‘I’ve lost it, Clive, I’ve lost it’, as the aircraft descended at high speed into the ocean. The chief pilot and manager of Seaview, who were on a separate company aircraft also flying to Lord Howe, heard the radio call but continued on, and after landing retired for the afternoon, apparently in good conscience, as Flight Service tried desperately to raise the missing aircraft. Nothing was found of it apart from two aerials, some cabin trim and seat cushions, a radio compartment panel and a section of wing insulation. There was no trace of the occupants.

    Conscience is often portrayed as an internal compass providing true direction when other cues fail. To conduct oneself with an approving conscience, to pursue principles along a line of reason as ‘straight and clear as a ray of light’ (to quote the 18th century radical philosopher, Thomas Paine), seems a noble ambition.

    The problem, especially in aviation safety, is that a ray of light is neither straight nor clear. It can be refracted, reflected, dispersed and warped. And what’s true for the metaphor is true for the subject: no person is an island; they exist within a continent of influences, compulsions and biases. They exist within culture. And culture has its own set of accepted values, behaviours and norms—each affirming, rebuking and modifying the thing we call conscience. In fact, by definition and by application, if culture is, as most definitions express it, ‘accepted values’ culture is conscience.

    So, while ‘let your conscience be your guide’ seems like good advice, what guides your conscience? What cultural atmospherics are distorting that ‘straight and clear ray of light’?

    How would culture influence your conscience in a small but busy aviation company where, as a newly licensed 25-year-old, you gladly accept a step-up pilot’s job? Applying the new guy’s old adage ‘eyes open, mouth shut’ you quietly refresh yourself on local procedures, aircraft technical matters and operations documentation. You’re excited about the opportunity and willing to make certain concessions to prove yourself—including long hours and low pay.

    You soon notice some inconsistencies. You notice the twin-engine aircraft you are to pilot must be regularly overloaded to ‘get the job done’. You notice the company, although operating as regular public transport (RPT), only has approval for charter work. You notice safety equipment such as life rafts is inaccessible. You notice other significant breaches of regulations. Then you start hearing tales of the previous chief pilot submitting confidential reports to the Civil Aviation Authority (CAA) after being sacked.

    You like the new chief pilot though, and he seems to like you. You notice he doesn’t seem to worry too much about being overloaded and regularly does it himself—again ‘to get the job done’. Perhaps you have considered broaching the subject with the chief pilot. Perhaps you are worried about the implications of a ramp check and have finally worked up the courage to raise the issues when you and the other company pilots receive a memo from the chief pilot. The memo is advice on how to respond to the regulator when you or the other pilots are questioned regarding company misdemeanours. The advice is firstly to ‘plead ignorance’, and if that doesn’t work ‘plead contrition’. The memo wraps up with ‘… only use believable bullshit—you [pilots] appear dumb, shouldn’t be too hard …’

    What is ‘guiding your conscience’ at this point? It might be, from fear of the regulator, ‘don’t breach the regs—it’s your licence if you get caught’. It might be, from a sense of professionalism, ‘come on, you know about airmanship—is this really appropriate?’ It might even be, when looking into the eyes of the passengers boarding your plane, ‘do they deserve all these safety deficiencies?’ But the dominant culture trumps all: the hand that signs the pay cheque gets the final say.

    The cruel twist of culture and conscience on that day was this: the passengers had the least control, with the most to lose. They always do. But what if the consciences of the passengers had been informed? What if, somehow, the safety cards (a cruel misnomer in this case) really had provided a snapshot of the safety of the aircraft?

    This is what they would have said …

    Welcome and thank you for flying with us. Your aircraft today is an Aero Commander 690 conducting an overwater flight to Lord Howe Island. 

    Your aircraft is probably overloaded by about 300kg. Your pilot is 25 years old and has 60 hours flying this type. He has an infection and is taking unregulated antibiotics and analgesics. His annual medical certificate elapsed last month and has not been renewed. 

    The latest weather report may or may not have been obtained and indicates the aircraft will be flying in significant icing conditions. There is a placard restricting flight into icing because of equipment deficiencies. 

    The maintenance control officer lives 500km away, in Wagga Wagga, and has acted as a clerk rather than directing and controlling maintenance. In the last 12 months numerous defects have not been recorded. Airworthiness directives have been actioned tardily, or not at all, and the right engine of your aircraft has exceeded a 5400-hour manufacturer’s limit. 

    The chief pilot of your airline was employed six months ago after the previous chief pilot was sacked. The sacked chief pilot reported directly to the Civil Aviation Authority (CAA) citing serious safety concerns. In recent years your ‘airline’ (in reality a charter operator) has been involved in 11 air safety reports and two of these allege unauthorised RPT operations in overloaded states with unsecured cargo and inaccessible life rafts. 

    In May your ‘airline’ was mentioned negatively in Parliament and numerous inspectors and managers within the CAA have failed to address these issues.

    Please ensure your seatbelt is buckled and enjoy your flight …

    It’s hard to imagine any passenger remaining on board after reading such a card. But of course the only information on the ‘safety’ cards was the normal emergency information.

    When asked at the subsequent commission of inquiry why no alarm had been raised, the manager and chief pilot replied they were unaware anything serious had occurred. It appeared the chief pilot was now following his earlier advice on ‘how to handle the regulator’, except that now the bullshit was no longer believable.

    Following is the transcript of the call between the chief pilot and the Rescue Coordination Centre (RCC).

    RCC: “… what are your thoughts on his comments ‘I’ve lost it with the vibration’? Lost control or lost …?”

    Chief pilot: “Can I speak off the record?”

    RCC: “Well I can call you back. This is a recorded tape.”

    Chief pilot: “Well my comment basically, the impression both John and I got [was] that he had lost control of the aeroplane … if the guy was still under control of course he would have said something …”

    The same question asked of the 25-year-old pilot can be asked of the disingenuous chief pilot; that is, ‘what is your conscience being told?’ It may be, by the fear of severe litigation, ‘I have to cover myself’. It may also be, by the fear of losing revenue, ‘I have to protect my job’. It may even be told, by fear of disrepute, ‘I have to protect my reputation or I may never work in this industry again’. The commission had its own ideas about why the lies were told—the main one being fear of a lost insurance payout.

    In any case the commission bluntly stated:

    The chief pilot and manager are lying … their failure to report was inexcusable. It was consistent with their having formed the view the aircraft had crashed … and there was nothing to be done … There was however a great deal to be done … elaborate search and rescue procedures have been established precisely because there is always the chance that somehow, miraculously, someone might survive. 

    The more authoritative conscience and culture of a $20-million commission of inquiry had little time for the ‘believable bullshit’ conscience and culture of Seaview Air.

    Other cultures were distorted. The commission heard how a CAA officer warned his superior, in Canberra, about Seaview. His report was passed to a district manager, who the commission found was ‘furious at having been bypassed’ and ‘determined to thwart the inquiry’. This he did, ensuring only token efforts were made.

    The commission would eventually ascribe responsibility for the accident to a ‘wanton operator and an incompetent and timid regulator’.

    As the managers of Seaview deceived in an accumulation of ‘small’ things they—pre-accident at least—were merely following a line of reasoning that appeared as ‘straight and clear as a ray of light’. In the full words of Paine’s quote—more poignant in this context—‘he whose heart is firm, and whose conscience approves his conduct, will pursue his principles unto death.’  Seaview’s managers allowed their conscience to be their guide, but failed to see it was being guided by a complex and powerful array of biases that would eventually see nine lives lost.

    If the lesson of Seaview Air can be condensed into a ‘bold-face item’ it should be this: for good or ill your culture is your conscience. Your organisational culture—your company’s shared ‘norms’ and shared assumptions are the value metric by which all other actions are measured. When the values are good and true they will be the atmosphere oxygenating conscience: when they are bad, they will suffocate conscience.

    And when we consider the modern motifs of ‘safety systems’, ‘safety culture’ and ‘compliance’ the Seaview lesson has a sobering corollary: it is possible to have a system—even a safety system—and not be safe. Seaview had safety cards in its aircraft—but it wasn’t safe. Seaview had an early form of what could loosely be called a safety culture—but it wasn’t safe. Seaview was even tacitly compliant with the regulator (in as much as the regulator hadn’t shut them down), but it wasn’t safe. It is of little value to have a safety management system and be tacitly compliant without a good and true safety conscience, without a robust safety culture. The product must match the billboard. The story of Seaview Air is a cautionary tale deserving our full attention when next we gauge our own culture and conscience. Or the next time we fly.

    Adrian Park is a pilot and safety manager with an east coast helicopter operator

    Suggested reading

    The Coroner: Investigating Sudden Death. Derrick Hand and Janet Fife-Yeomans (Memoirs of NSW State Coroner, Derrick Hand, including his account of the Seaview Investigation.)

    Investigation Report 9402804, Rockwell Commander 690B VH-SVQ en route Williamtown to Lord Howe Island New South Wales. 2 October 1994, Department of Transport and Regional Development, Bureau of Air Safety Investigation.

    Commission of Inquiry into the Relations between the Civil Aviation Authority and Seaview Air, 1996

    Controlling Pilot Error: Culture, Environment, and CRM, Anthony T. Kern 2001

    Just Culture: Balancing Safety and Accountability, Sidney Dekker, 2007

    24 COMMENTS

    1. My new bride and I were supposed to have flown to Lord Howe on that flight, but managed to secure two seats ex Sydney in a Chieftain on the Monday beforehand.

      That flight saw the ground crew replacing two passenger seats beforewe boarded… The alarm bells were already ringing.. As soon as we got in, and seated, the aircraft was loaded to the rafters with freight. I remember a liferaft being the last item loaded.. and the door crunching down on some of the freight.

      I knew that I could not climb over the freight to the door in a ditching, and was working out how to extricate myself though the passenger windows if we ditched.

      The alarm bells were screaming now, and we had not even started the engines..

      Seaview issued us with boarding passes, and tickets, so to all intents and purposes, we assumed it was an RPT flight not a charter…. twenty years down the track, and after flight lessons, I learned the difference, and could see the glaring safety errors made by a company cutting corners and costs.

      The flight was not without its interesting moments, like watching the tanks drain their fuel with thirsty engines, icing at 11,000ft, Rime ice, not just hoarfrost. On approach to Lord Howe the owner of the company told his new recruit to simply overfly the township (to alert the folks they were arriving) and simply proceed with a landing direct to runway 10 as the fuel gauges were reading empty.

      We stayed at the island for three weeks, and it was simply a magical wonderland, but with the loss of the Aerocommander, we decided to change airlines (they were presenting themselves as an RPT operation) and found no refund was available, we decided to fly in a Qantas Dash 8 to get home.

      The worst part of the ordeal was being summonsed as a witness to the Commission, and being told bluntly by councel for Seavier that I was a liar. The liars in that courtroom were seaview themselves.

    2. Stumbling upon this article, reading and absorbing it. Checking out the MoU between CASA and the ATSB…the game of dodge. Cost lives, compromises safety, use of tax payer money for an inquiry. Bureaucrats squabbling in the name of avoiding any accountability. Yet they write the rules.
      I scratch my head.
      Truth and honesty trickle from the top. Have examples of strong leadership with “good will” happen yet?
      I personally have not seen this displayed.
      If the truth was just told from the start, perhaps history could have been different.

      As I braced for death, slammed into the ocean, a Half-inflated life vest. Terrified of sharks, freezing, hurt, fighting to live with every piece of energy. Start to give up within after over an hour of treading water in an angry ocean as I held my patient close. She was brave and so was her husband. Deserved better treatment from our Government.

      Some parallels.
      If I knew we were flying around the South Pacific, Ad-Hoc MedeVacs with many variables, unprotected with the correct oversight in place from thy ones who make the rules/law/, informed, I would not have flown.

      I don’t know what category we were under or the AOC status for that flight.

      Most know of the serious safety alert from a 2008 audit. The “Special Audit” not given to the ATSB.
      I have it. A no brainier would have been to alert them.
      So pretty much, same as twenty years ago. Levels of failure from all three.
      Conscious. No. I don’t believe so.

      No Law/Policy addressing International MedeVacs. High risk field, one would think.
      No Law regarding above post ditching
      No protection from an Authority with statutory rights from 1996 to today, which are being examined, closely.
      Why would Ministers allow (both sides) for this to continue on?
      Lawyers don’t fly planes and pilots don’t right rules.
      Mutual respect without inflated egos might help too.
      Industry is voicing, so are ghosts of the past along with current, factual evidence which keeps bouncing off that dome.

      The human element of consciousness from the Operator, CASA and the ATSB are all still questionable to this day., I believe.

      That protective dome, allows the ones who write the rules to not be accountable. Ever. Stat

      I would be very interested in an article regarding the same thought given to the management of the Pel-Air incident thus far.

      Five, very long years. 18/09/2009

      Also, why was there rope on the rear of the aircraft, the fuselage has moved it seems? Peculiar?
      Just thinking. Why?

      Twenty years of learning. Where?
      I must ask?

      Good article. Thank you

    3. I have no words to describe the past week. In particular this evening.
      Vivid is an understatement.

      I can assure you that the psychological trauma begins before the ditch into the endless ocean. It began in the air. As we circled.

      My question, tone answered honestly please.

      Were we in NZ Airspace when my legs turned to jelly and I felt my fate. Which haunts me every day as each sting of pain reminds me.

      Therefore, psychological trauma could have began in NZ airspace??
      Bodily injuries, full impact where I sat, into the Ocean. Norfolk jurisdiction??

      If lessons could be learned with this current opportunity for a change of culture. If the truth told.

      Just get it right.

      Break the political cycle of bantering aviation safety laws/reforms.

      Absolute nightmare. Believe me.

      Tut tut…twenty years. Dear oh dear.

      I shake my head. As I am wasting my time bothering anymore.

      Butt heads. Be ridiculous regarding serious matters. Ignore those who needed your help not your avoidance.

    4. Reading this article our heart breaks for the families left behind. -to lose daughter, son, brother, sister is hard enough.
      But to lose them so needlessly and to such incompetence is beyond cruel. Our hearts go out to those who are left behind and who remember.

      • Kerry my brother was Anthony Atkinson his wife was Leeca Maria Atkinson they were the newlyweds on the seaview flight. You have no idea how this as destroyed us. But thank you for your kind words

    5. My name is Mathew Atkinson I have lived 21 years with this disaster burning in my soul. My brother and his wife were the newly married couple on this plane. Thank you to Adrian Park for finally putting into words the truth it was just one big [stuff] up. Adrian thank you for expressing the truth. The fact of the matter 21 years later planes are still falling out of the sky for the same reasons nothing has been done. There is a continued waste of life

      kind regards
      Mathew Atkinson

      • And a continually denial from the “governing” agencies. Remind me how many times the “CAA ” (as it was called at the time) changed its name after the accident due to being in possession of a manufactor s press release recalling this model air craft for SIX WHOLE MONTHS PRIOR to this accident. If this had of been released immediately this air craft would have been rectified and these lives not lost.
        There is so much more I could say but best we leave this hurt where it lies

        • We best not leave this hurt where it is. We need to fight to ensure it does not happen again.

          Safety starts with the owner and the Minister. In this case, some jail time for the relevant owner, the CAA District Manager and the head of CAA would have been appropriate. Their actions, or lack of them, amounts to criminal negligence.

        • Please say what needs to be said people die lives are destroyed and those responsible think that it is ok. Money and greed over lives

    6. I met the manager when he was a DCA radio technician in 1976. He was shrewd and unscrupulous back then, and this whole affair is unfortunately no surprise. He became the DCA radio technician on Lord How in about 1979, and whilst being handsomely paid for apparently doing very little (according to a “CONTACT” magazine article), he kicked off his airline. I remember him saying that he married “for money”, so perhaps this was how he bankrolled the operation. It was said that Departmental vehicles were often used for freight handling at each end. There were also rumours that airworthiness inspectors could benefit from free accommodation on the island. Indeed we bear the Burden of Proof but it all seems more than co-incidence. Dick Smith once spoke of “Affordable Safety”…..At what point then is Human Life the cheaper alternative. Not long after this crash, the Civil Aviation Authority changed its’ name to Air Services Australia. I wonder why…
      My Condolences to those of you who still grieve…

    7. Mathew i have often thought of your family and leecas over the years the day my brother-inlaw rang me to tell me the plain had crashed is still so vived i only met leeca and anthony once out at john lavreriks with my sister and her hubby ..my heart gos out to you all .. john is now wjth his much loved daughter .

    8. […] 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 […]

    Leave a Reply