The Ditching of Australian Aviation Governance: Pel-Air Revisited – Part 4

The fragility of life: Karen’s world

There is a light breeze surrounding me as I soar gracefully over beautiful green fields. On my right I can see the coastline and a brilliant blue ocean, the sea looks calm and soft and I can hear the gentle tones of the sea as the waves roll onto the sand. I’m in complete control. I have a sense of happiness, exhilaration, and calm, and am able to easily manoeuvre myself around the horizon. It’s as if I’m not in an aircraft – I’m flying, soaring like an eagle with a free-spirited energy I’ve not experienced for a long, long time. It’s like returning to a childhood holiday: warm, calm and relaxed. If only I could stay in this happy place, completely at peace, satisfied, carefree…

Now where am I? What is all this pain? I am closing my eyes in a desperate attempt to go back to that happy place. I cannot get back there; the pain is increasing, my body aches, yet I’m slowly regaining conscious thought. 

It is dark, I am cold, scared and confused. It was a beautiful dream but now I’m back to reality, the constant pain is still there, it never (expletive) goes away and my life is now consumed by it. The same (expletive) process, fighting the system, constant anger, grief, frustration and yet another sleepless night. 

Lying awake, I’m watching the clock countdown to take me from now (it is 2 am) to daylight, and I’m contemplating whether I can do this anymore. Can I keep up this fight? Is there any way I can go back to my dream and remove the pain? There are options but the consequences for my son and daughters would be lifelong. I have a sense of guilt for even thinking such thoughts. For goodness’ sake, I’ve spent a career caring for people – it is my fundamental purpose and destiny in life. 

My name is Karen, and I’m the flight nurse that survived the Pel-Air ditching at Norfolk Island. 

I will never again be able to experience the joys associated with the freedom of flight.

My life changed in the blink of an eyelid. Literally overnight, almost nine years ago, life as I knew it changed forever. I no longer have the normal sense of purpose that comes with an exciting aviation job: the deep satisfaction of performing meaningful work that you care about, the camaraderie, friendships, the excitement of not knowing what you will be doing day-to-day, or which destination is next for a medical evacuation. I miss the laughter, the sense of purpose, and the workplace banter that is unique to air ambulance and aviation operations. For me, each day is now a struggle, a constant grey landscape where I no longer gain the deep satisfaction that I once had with life.

‘My life changed in the blink of an eyelid.’

As a single mum I worked harder than many, raising my three children while also completing university studies to shape a better life for my kids. Overnight, my income went from just over six figures to $37k. The struggles were huge: financial stress, three kids to take care of, seven operations, battling to make sense of the regulatory process, the accident investigation, and fighting through the courts. And on top of that, having to deal with insurance companies that took every step to make life as difficult as possible for the survivors.

Just like air crash investigators, it is ironic that I now use the words ‘if only I had known in hindsight’! Had I known there were inadequate safety regulations for Air Ambulance I would not have flown. I had no idea we were not protected by robust legislation, that it was acceptable for smaller operators to venture into complex, back of the clock, short-notice medical retrieval operations with limited oversight and company standards. Those same companies paid the aircrew small wages in comparison to larger organisations, which inevitably meant the levels of experience were substantially lower and the turnover of crew high, resulting in more challenges when undertaking these more complex tasks.

And after all these years the facts get blurred and I get tired. I’ve found information that suggests larger political donations were made after this accident – not surprising given a senior member working to protect the company was a former Transport Minister. 

My journey has been horrific: trying to penetrate what feel like walls of deceit, lies and corruption, all generated from several people with very large egos. Again, it is ironic that air crash investigators often mention a need to understand your own bias, or that of a collective team, to make sure the investigation process is not adversely influenced. In my case, I feel egos have heavily influenced many processes to make life difficult; at times, unbearable. 

I will never fly again, not because I’m scared of dying in a plane crash but because I’m scared that if I survived I could not bear to live through this hell again. The treatment has been nothing short of cruel and disgraceful, and sometimes I do not know how I have survived for this long. 

But one thing I can tell you, I am the epitome of a strong, independent woman. And I will not give up this fight, not until the energy and the exorbitant amount of tax payer resources (senate enquires, independent reviews, a second investigation, court cases, etc.) lead to enhancements to the Australian aviation system to prevent you and your loved ones from ever experiencing the same.

Egos and failed governance

Ego can be described as a person’s sense of self-esteem and self-importance. Everyone has an ego; it is a natural facet of our humanity. The way we invest our egos has major implications on the way we act, what we believe, and how we respond to adversity such as criticism, insults and failure. 

It is also worth noting that the ego largely stems from one’s personal experiences. For many people it is challenging to view issues or results rationally if their beliefs are clouded too deeply in their ego. One must always be open-minded to change and criticism. For some, this proves very difficult.

Looking back on the Pel-Air Norfolk Island ditching as the then Human Factors Manager for the Civil Aviation Safety Authority (CASA), there are many memories that make it feel like it all happened yesterday.

At the time, there were a few senior managers within CASA with very firm and clear views right from the start, even before the Australian Transport Safety Bureau (ATSB) had commenced its investigation. 

A strong view was held by one person that the investigation process should focus primarily on the pilot. I remember hearing dissatisfaction expressed by this person as to why anyone would be wasting their time with other systemic findings. Looking back at some of the statements made by this person:

In the end it is only the pilot that can decide whether he or she is fatigued and unable to conduct a flight… 

This was an interesting statement that contradicted the fatigue science and best practice available at the time. Fatigue is insidious, hence the crew themselves can lose the ability to self-assess. This is why it is so critical to have robust organisational and supervisory support mechanisms to further monitor pilot performance, particularly when conducting ad hoc, aeromedical evacuation flights. The comment is made from a personal basis rather than an informed basis, likely to protect one’s own belief and position.

This same person discussed the use of software to support crew flight planning:

The software is only a thing of today, you can do this manually… when I started flying 40 years ago of course software didn’t exist… examinations tested theoretical knowledge of how you make those calculations and they can be done by longhand as well as by computerised software.

This was another statement based on a model of the world shaped by personal experience but not one that is demonstrating an open mind to want to understand how cultural differences effected this aviation accident.

There were also leadership characteristics observed at the time that drove a culture of fear amongst middle and senior managers. This can have detrimental affects within any organisation, particularly when the communication flow is in one direction (down) and messages are changed when moving back up to ensure they meet the expectations of more senior personnel. I’m sure many of you have seen this in different organisations where middle managers feel the need to water down what is really going on to placate the egos of a few at the top.

Although anecdotal, the investigatory process appeared to worsen over time. There were rumours that senior personnel within the ATSB were involved with re-writing sections of the first investigation report to better align with the beliefs of other external senior personnel, including the need to meet the agenda and beliefs from within CASA. 

Making matters worse, an audit of CASA’s processes just prior to the accident by the International Civil Aviation Organization (ICAO) and/or the Federal Aviation Authority (FAA) was critical of several internal CASA processes, including the quality of training of CASA staff. In my mind this was potentially feeding the need to deflect any further adverse findings away from CASA back to the operator, in this case, the aircraft captain. There was enough scrutiny of CASA’s own processes without the addition of an ATSB accident investigation report that had clear evidence within the CASA Pel Air Special Audit of systemic failures with CASA oversight. Yet, for the first investigation this information was not included or considered relevant by the then Commissioner of the ATSB.

If all of this is true, it must have been a very destructive and damaging outcome for the ATSB investigators who, unknowingly at the time, were about to have their professionalism and credibility tested in the public eye.  

I know of at least one ATSB investigator whose career was destroyed as an outcome of this investigation, all because several egos with self-focused agendas were allowed to unnecessarily influence the process. Senior managers unwittingly contributed to a flawed investigatory process right from the start, and confusion reigned. The investigatory policy and process were robust, yet egos clearly contributed to failed governance, ultimately leading to the following findings by the Transport Safety Board of Canada after completing an independent review of the ATSB:

• …an early misunderstanding of the responsibilities of CASA and the ATSB in the investigation was never resolved…

• …this misunderstanding persisted throughout the investigation, and as a result, only two ATSB interviews were conducted with managers and pilots of the aircraft operator…

• ….errors and flawed analysis stemming from the poor application of existing processes were not mitigated…

Recognising ego and power

Unconstrained ego and power destroys lives. For Karen, the outcome of failed Australian aviation governance is a shattered life. Other more recent examples of the impact of ego and power have been seen through the ongoing banking sector royal commission, where the lives of many Australians have also been destroyed. 

So, what can you and I do to protect ourselves?

Leveraging from the work of a long-time mentor of mine, Dr Tony Kern, the author of a number of aviation books, including Blue Threat: Why to Err is Inhuman and Going Pro: The Deliberate Practice of Professionalism, ego and power is identified as a known violation producing condition that requires careful consideration and management in the aviation industry.

If allowed to grow, it can become a belief that the violator has the skill and stature to do the job better outside the boundaries. It is particularly dangerous because it lives inside most high achievers. 

Somewhere in our lives, most of us will admit that we have moments where we think we are smarter than the people who wrote the rules. This may or may not be true, but it is a dangerously irrelevant question when it comes to compliance. 

Here are a few red flags from Tony’s work to warn us when our egos start to get in the way of our common sense:

• You find yourself being defensive about an idea or plan and taking it personally when someone disagrees with your ideas. This often leads to noncompliance to prove yourself and your idea can lead to mission accomplishment. 
• You routinely make a point of showcasing your brilliance, as in ‘those rules don’t apply here because…’.
• You view colleagues as rivals and are willing to bend the rules to ‘one up’ them.
• You disagree with someone simply because you did not come up with the idea first.
• You prematurely criticise policies or procedures that get in the way of your goals without considering their value. 

Keep in mind that as individual human beings we are limited, and when we continually compare ourselves to others in an attempt at ego gratification, we often end up looking foolish and unprofessional by our wilful noncompliance.

‘Keep in mind that as individual human beings we are limited.’

And this process can start as you become more confident with experience. As an example, when you first learn about longer radio calls from Air Traffic Control (ATC), hopefully the guidance has been to write the message down on a knee pad before reading the information back. You carefully and neatly write it down, pause to collect your thoughts and then read the information back clearly, but not too quickly, to ensure ATC also have the time to process (check) that you have received the correct information. 

But, as you gain more experience and confidence there is the propensity to perform this process from memory with an urge to read the information back quickly, just to let ATC and others know that you are highly proficient. Wow, how did you remember all that information and read it back so quickly? You must be very good at what you do.

If you allow this to become your new habit pattern, then no surprises that somewhere down the track you will make an error. Perhaps you’ll be levelling off after take-off at 3000-feet when in fact you were meant to level off at 2000-feet. 

The most professional aviators instil good habit patterns. I admire the slight pregnant pause from operators at airfields in between making their readback to ATC because I know they are taking the time to write down and process the information more accurately than the over-confident quick talker, who is also the type that is known for taxiing the aircraft a little too fast. 

Furthermore, keeping your ego calibrated – being able to acknowledge your flaws in both your personal and professional life – also builds trust.

High performance and self-awareness

For any high performer you should always be open-minded to change and improvement because the world is constantly changing and adapting. Investing your ego into beliefs to the point where you cannot change them in the face of evidence is one of the most foolish things you can do. It is critical to always keep yourself open-minded to new information and hard facts.

Take the time to consider the points above, particularly anytime you show signs of being defensive when receiving feedback from others. Similarly, if you start to blame the system (it was the fault of ATC, you did not brief me properly, it is not my fault) then you are entering a phase in your career that can be difficult to overcome. High performers remain open to considering better ways of doing business; the process of seeking good habit patterns breeds a higher level of self-awareness. And good self-awareness, from my experience, is the most critical factor in understanding your own limitations and what you are truly capable of. With this you can consistently make better decisions to operate within your own personal boundaries of performance. 

Working hard at improving self-awareness, always seeking to improve your personal habits and techniques while accepting feedback openly is positioning you to become a lifelong learner, un-encumbered by ego and a great leader. 

Thinking back to Karen and given the depth of material she has discovered since the accident, it is no wonder she has so little trust in CASA and the ATSB. She has experienced unconstrained ego and power from the very people she needed (and expected) to do their jobs well. 

Next month in my final article of this series, the focus will be on the importance of trust, along with some guidance on how CASA and the ATSB can enhance their trust relationship with the Australian aviation community.