Swedish accident reports – produced by the Statens Haverikommissionen as you will all know – make unusually educational reading. For whatever reason the agency is notably inclined to explore what investigators call the institutional factors in accidents. They don’t in any sense go easy on the individuals on the day who they think underperform. But they do investigate in considerable detail how come those individuals, often very capable, did what they did on the day.
In this report just out they take a long look at the management and oversight over a lengthy period of the Swedish police flying service, and they’re not hugely impressed. The end result was a pilot who died flying a Eurocopter EC135 helicopter in benign conditions, and three passengers with serious injuries (although astonishingly light ones in the circumstances.)
It’s a fascinating document and I’d encourage you to find a little time to go through it, perhaps even to think about how relevant it is to your own organisation.
To give you a flavour, here is the paragraph headed simply “Causes of the Accident”:
The accident was the result of, partly, deficiencies in the direction of SPW, partly, the unclear granting of permits by the Civil Aviation Authority and its inadequate inspection which permitted a dangerous flying activity. Triggering factors were the pilot’s performance of the flight in combination with the possibility that the snow skids mounted on the helicopter may have affected the flight properties of the helicopterunder extreme flying conditions.
This item I wrote last week also illustrates my point about the Swedes’ focus on institutional factors.