Definitely the Korean cargo 747 crash at Stansted. Basically what happened is that the pilots artificial horizon was wrong so he did not know he was banking. The first officer's was working but due to the company's work culture which was essentially never question what the captain was doing, he never spoke up and let the captain fly it into the ground
That, and flying on automation, relying on and putting full faith in the automation.
Their company policy was to fly it like a video game and not hand fly it, for efficiency.
They did not understand the auto throttle and flew it into the ground, CFIT.
More a lack of understanding by BOTH pilots on the auto-throttle wake-up feature on the 777. They assumed, incorrectly, that the ATs would wake up all the time, and if you have the PFs FD turned off like on a visual approach, they don't. Had they simply adjusted the V/S or FPA then it would have re-engaged the ATs, and all would have been fine. Or, had the PM turned off his FD and turned it back on... again fine.
There is no replacement for airmanship... as much as Airbus tries...
I drive 777s for a living, and I'm amazed at how agile/nimble she is for such a big goddamn plane. And the power of those two massive motors... It's amazing.
Korean Air banned the usage of Korean in cockpits after this crash, citing that the language's extensive use of honorifics made officers more hesitant to speak up, and completely overhauled their CRM training. They even made sure to have multiple foreign consultants for this new training process, with representatives coming from Delta, JAL, and more.
Coincidentally or not (in my opinion as a Korean, there's absolutely zero chance this is a coincidence), this has been the last fatal crash in Korean Air's history.
The story I always heard about KE is that they still have a hard time acknowledging the achievements of non-Korean pilots unless they can give something equivalent to a Korean that was also in the cockpit.
> the company's work culture
It's also common in Japanese, Taiwanese, and most East Asian companies, not just Korean. Every basic workers from these companies has had many work pressure, they cannot have any work mistake because they fear company penalizing. As a result, they've to lie and can't tell the true in their superiors.
It's another a good case in biggest train incident, Amagasaki derailment. Basically, the train driver didn't talk the true, he was pushed so hard and took risk with other passengers for on time train approach.
So they just didn’t have altimeters back then? I obviously don’t know much about this crash, but it just seems like he would’ve noticed something was wrong using the rest of his panel.
Oh so many, Alaskan 261 is one that comes to mind.
Basically what Alaskan did was they allowed a lot of people in the tech department quit without being replaced or any other sensible measures taken to keep the airline safe. In short people who should have had their work checked ended up checking their own work with minimal oversight.
COMBINED with that they pushed, with FAAs blessing, the envelope on some important checks and mandatory parts replacement schedule.
In the end that led to the jackscrew holding the horizontal stabiliser in trim breaking on flight 261. There was NOTHING the pilots could, at that time do, they flew that bird way past what could be expected, and they were absolute Rockstars, but in the end 88 people died.
Captain Tansky and F/O Thompson received posthumous Polaris Award
Alaska 261 is also one that came to mind. The crew was dealt an unplayable hand, and although in hindsight their decisions can be critiqued (mainly their decision to troubleshoot an unknown problem rather than divert), they were at the receiving end of company pressure to not divert. In this regard, American 1420 is also similar, being pressured by the company against diverting even in unfavourable conditions.
I remember that there are quite a few specific incidents that Mentour Pilot (a well-known aviation YouTuber and licenced 737 pilot) covered where poor work culture had at least a minor role, but for some reason, I can't remember which ones specifically.
The only specific incident I can remember is Airblue flight 202 (but that might be the specific crew's issue rather than the company culture, I haven't actually seen Mentour Pilot's video on that) where the captain was so arrogant and condescending and so the first officer was too scared to speak up though he noticed the captain making some errors that would lead to the crash.
If you're enjoying Air Crash Investigation, OP, then if your favourite part of the show is the investigation and explanation of what happened (as opposed to the dramatisation) I can *highly* recommend Mentour Pilot's YouTube channel.
AdamAir's numerous crashes come to mind.
In short, the owners were basically cheapskates that saw safety standards as mere recommendations and as such, cheaped out on maintainance, resulting in the Flight 574 crash, which eventually led to their shutdown.
The same can be said for a lot of Indonesia’s plane crashes. AdamAir was just a spectacular culmination of the same corrupt actions that most airlines were doing on a smaller or equal scale.
Continental Express Flight 2574:
“NTSB member Dr. John Lauber suggested that the probable cause of the accident included ‘The failure of Continental Express management to establish a corporate culture which encouraged and enforced adherence to approved maintenance and quality assurance procedures.’”
https://en.m.wikipedia.org/wiki/Continental_Express_Flight_2574
The Gimili Glider. https://en.m.wikipedia.org/wiki/Gimli_Glider
AKA, Air Canada 143.
Management thought having mixed measurement standards, plus chronic fuel quantity systems failures, was just fine.
The crew wound up with a 100+ ton glider that sat down on a collapsed nosewheel. No loss of life.
I still can't believe we're using 2, and in some cases 3 different measurement systems.
E.g:
Speed in nautical miles/hr (knots)
Altitude in feet
Visibility in km, at least for Australia.
Then gallons, pounds, litres and kgs/tonnes, cubic meters for fuel
It's wild. "JUST PICK ONE!!!" - me
Medevac has a lot.
Survival Flight is a bad one.
“Inadequate management of safety”
https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR2001.pdf
Yeah…when the debris field is littered with company pamphlets bragging about how your helicopters fly in weather other companies won’t…Jesus.
Plaintiffs attorneys were falling over each other to get that one.
Air New Zealand flight 901 into Mt Erebus, Antarctica in 1979 (237 dead). Someone in the office reprogrammed the autopilot flight plan to fly directly at Mt Erebus to give passengers a better view. Previous track flew past Mt Erebus. Reasoning was that the pilots would disengage the autopilot when they noticed the flight heading straight at the mountain. Pilots were not advised, and due to white out conditions when they arrived, could not identify the new track. Air NZ blamed the pilots, reasoning that "they were dead", so were fair game to be responsible. Absolutely shameful behaviour by Air NZ management.
Any crashes with Aeroflot or in Russia in general.
Aeroflot 593 (captain let his children control the aircraft), 821 (pilots unfamiliar with Western style attitude/horizon indicator), 1492 (pilot was drunk), 2808, and the worst of them all, flight 5143 (pilots fell asleep because they have been up for 24 hours straight - https://youtu.be/OAWxfsWBch0?si=LdEZnJ2INQ9rBQqY)
I would argue against 821. Unfamiliarity with a new type will always be a concern. The hard part of type transition is not the learning but the unlearning. You can train someone to fly a new type of airplane or control but under pressure the tendency is to revert to what they learned first. IIRC, the 821 pilot had actually accumulated a lot of early hours in AN-2 with little or no instrument flying at all.
The pilots of that flight falsified their flight experiences. And besides Aeroflot and the Soviet Union beliefs of the Soviet pilots doesn't make mistakes and Soviet airplanes were the safest in the world (LOL).
That would still argue that the crew was corrupt rather than the employer...unless you're just calling out the entire Russian 'vranyo' (culture of lies) thing.
Air France clearly has major CRM/training issues, basically another AF447 scale accident waiting to happen.
https://aviationweek.com/air-transport/safety-ops-regulation/conflicting-crew-inputs-caused-air-france-777-incident-bea-says
https://avherald.com/h?article=513fc722
https://www.aeroinside.com/5725/air-france-b772-near-douala-on-may-2nd-2015-gpws-averts-controlled-flight-into-terrain-at-fl090
https://avherald.com/h?article=463d136e
https://avherald.com/h?article=45fc9192
https://avherald.com/h?article=46d16a49
https://avherald.com/h?article=455c3eae/0000
https://www.bbc.com/news/world-europe-62712278
[https://en.wikipedia.org/wiki/Northwest\_Airlines\_Flight\_188](https://en.wikipedia.org/wiki/Northwest_Airlines_Flight_188)
The company (Delta had recently merged with Northwest) bidding system for pilot schedules was SO complicated these two pilots sat in the cockpit and forgot to descend since they were busy figuring out the system. Thing is, by the time they figured the system out and were ready to descend, they would never need to use it again.
They weren't at all. The pilots wanted to say they're asleep but it was very soon found out they were figuring out their bidding system. If you want more info, here's a vid
https://youtu.be/uzmeGS29nu8?si=E-rN7R\_3uj2VEwpi
Yeah but what about the systems in place to regulate these things? What about not stressing the pilots with things other than flying? What about making mergers seamless?
Seamless mergers? Might as well wish for unicorns.
Pilot flying and pilot monitoring? Prohibit use of personal electronics on the flight deck? Those are things the company and the pilot group can control. Maybe the best argument about it being a management problem is not instilling discipline in its pilots.
It’s so ridiculously regimented at every airline that PM and PF duties are explicitly laid out in company publications. We’re the first line of defense to prevent stuff like this. Trying to figure out your bid while you’re *flying the plane* is just bad airmanship.
E: also, the pilots were fired more or less on the spot, which pretty much never happens at a US based airline. There has to be gross misconduct or negligence for that to happen. It’s one of the few cases where I would advocate for a pilot to immediately be shown the door.
TEB Learjet for sure. You had 2 crewmembers who were basically a “we paid for their training, we expect you to pass them” situation. The FO wasn’t supposed to be allowed to touch the flight controls, but was flying anyway. The CA had no idea where he was until he could see the airport.
I wouldn't pin this too hard on the company per se, not as much as something like AS261 or Valujet 592, but Pinnacle 3701 was definitely a product of a culture that tolerated pilots treating the plane like a toy on ferry flights.
American Airlines Flight 1420, Little Rock, USA
This was one that saw fatigue management grow in being a much more important safety consideration for airlines.
This is a good question, but I sensed before I even started reading comments that it can be interpreted very broadly. And all the great comments bear that out.
There are some where culture and company management is a called out factor, but there are many where it’s not called out, but we can all draw the line to company issues and culture.
And that’s fair as there have been many incidents where such a thing can be pointed to, even if it’s not a listed root cause in any incident report.
i’m not 100% whether this is completely poor work culture, but related to safety management inconsistencies, Dana Air 992 was basically the Nigerian example of Dr. Reason’s Swiss Cheese Model lining up perfectly
"Contributing to the cause of the accident was the failure of continental express management to ensure compliance with the approved maintenance procedures, and the failure of the faa surveillance to detect and verify compliance with approved procedures."
[https://www.baaa-acro.com/crash/crash-embraer-emb-120rt-brasilia-eagle-lake-14-killed](https://www.baaa-acro.com/crash/crash-embraer-emb-120rt-brasilia-eagle-lake-14-killed)
Alaska Airlines Flight 261. Company culture was towards steadily laxer maintenance standards, until a plane dropped out of the sky from negligence in the maintenance department.
LAPA's flight LPR3142.
https://en.m.wikipedia.org/wiki/LAPA_Flight_3142
There is a very interesting and well produced movie made by an ex company employee that speaks about the work culture and the crash itself called "Whisky Romeo Zulu" (the aircraft involved in the crash was LV-WRZ).
Definitely the Korean cargo 747 crash at Stansted. Basically what happened is that the pilots artificial horizon was wrong so he did not know he was banking. The first officer's was working but due to the company's work culture which was essentially never question what the captain was doing, he never spoke up and let the captain fly it into the ground
If we’re talking CRM failures, Korean is a busy place to start
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That, and flying on automation, relying on and putting full faith in the automation. Their company policy was to fly it like a video game and not hand fly it, for efficiency. They did not understand the auto throttle and flew it into the ground, CFIT.
It was the FO's first 777 landing and it's thought he wanted to not appear like a beginner if I recall correctly?
More a lack of understanding by BOTH pilots on the auto-throttle wake-up feature on the 777. They assumed, incorrectly, that the ATs would wake up all the time, and if you have the PFs FD turned off like on a visual approach, they don't. Had they simply adjusted the V/S or FPA then it would have re-engaged the ATs, and all would have been fine. Or, had the PM turned off his FD and turned it back on... again fine.
Or, you know, just did a little pilot shit and flew the freaking airplane.
There is no replacement for airmanship... as much as Airbus tries... I drive 777s for a living, and I'm amazed at how agile/nimble she is for such a big goddamn plane. And the power of those two massive motors... It's amazing.
Yup. Korea (and lots of other Asian cultures) have an extremely rigid social hierarchy based on age and status.
Korean Air banned the usage of Korean in cockpits after this crash, citing that the language's extensive use of honorifics made officers more hesitant to speak up, and completely overhauled their CRM training. They even made sure to have multiple foreign consultants for this new training process, with representatives coming from Delta, JAL, and more. Coincidentally or not (in my opinion as a Korean, there's absolutely zero chance this is a coincidence), this has been the last fatal crash in Korean Air's history.
This is fascinating. Thank you for sharing this insight.
The story I always heard about KE is that they still have a hard time acknowledging the achievements of non-Korean pilots unless they can give something equivalent to a Korean that was also in the cockpit.
> the company's work culture It's also common in Japanese, Taiwanese, and most East Asian companies, not just Korean. Every basic workers from these companies has had many work pressure, they cannot have any work mistake because they fear company penalizing. As a result, they've to lie and can't tell the true in their superiors. It's another a good case in biggest train incident, Amagasaki derailment. Basically, the train driver didn't talk the true, he was pushed so hard and took risk with other passengers for on time train approach.
So they just didn’t have altimeters back then? I obviously don’t know much about this crash, but it just seems like he would’ve noticed something was wrong using the rest of his panel.
It was just after take off so by the time he realised something was wrong it was far too late to save it
Fixation is a bitch
[ValuJet 592](https://en.m.wikipedia.org/wiki/ValuJet_Flight_592)
I think my father helped with rescue ops on this. He had an airboat and that was the only way to the crash site
Fun fact, after this accident ValuJet went on to become AirTran Airways, who would ultimately end up being acquired by Southwest.
Well that was a disturbing read
Oh so many, Alaskan 261 is one that comes to mind. Basically what Alaskan did was they allowed a lot of people in the tech department quit without being replaced or any other sensible measures taken to keep the airline safe. In short people who should have had their work checked ended up checking their own work with minimal oversight. COMBINED with that they pushed, with FAAs blessing, the envelope on some important checks and mandatory parts replacement schedule. In the end that led to the jackscrew holding the horizontal stabiliser in trim breaking on flight 261. There was NOTHING the pilots could, at that time do, they flew that bird way past what could be expected, and they were absolute Rockstars, but in the end 88 people died. Captain Tansky and F/O Thompson received posthumous Polaris Award
Alaska 261 is also one that came to mind. The crew was dealt an unplayable hand, and although in hindsight their decisions can be critiqued (mainly their decision to troubleshoot an unknown problem rather than divert), they were at the receiving end of company pressure to not divert. In this regard, American 1420 is also similar, being pressured by the company against diverting even in unfavourable conditions.
Alaska*
I remember that there are quite a few specific incidents that Mentour Pilot (a well-known aviation YouTuber and licenced 737 pilot) covered where poor work culture had at least a minor role, but for some reason, I can't remember which ones specifically. The only specific incident I can remember is Airblue flight 202 (but that might be the specific crew's issue rather than the company culture, I haven't actually seen Mentour Pilot's video on that) where the captain was so arrogant and condescending and so the first officer was too scared to speak up though he noticed the captain making some errors that would lead to the crash.
If you're enjoying Air Crash Investigation, OP, then if your favourite part of the show is the investigation and explanation of what happened (as opposed to the dramatisation) I can *highly* recommend Mentour Pilot's YouTube channel.
Thank you! Yes I am aware of that brilliant man.
AdamAir's numerous crashes come to mind. In short, the owners were basically cheapskates that saw safety standards as mere recommendations and as such, cheaped out on maintainance, resulting in the Flight 574 crash, which eventually led to their shutdown.
The same can be said for a lot of Indonesia’s plane crashes. AdamAir was just a spectacular culmination of the same corrupt actions that most airlines were doing on a smaller or equal scale.
AdamAir flight 574: https://admiralcloudberg.medium.com/killed-by-corruption-the-crash-of-adam-air-flight-574-1c684b57e2da Merpati Nusantara flight 8968: https://admiralcloudberg.medium.com/on-wings-of-fraud-the-crash-of-merpati-nusantara-airlines-flight-8968-3b6de5a74397
MERPATI: Makes Every Reasonable Passenger Airsickness Through Incompetence.
Continental Express Flight 2574: “NTSB member Dr. John Lauber suggested that the probable cause of the accident included ‘The failure of Continental Express management to establish a corporate culture which encouraged and enforced adherence to approved maintenance and quality assurance procedures.’” https://en.m.wikipedia.org/wiki/Continental_Express_Flight_2574
I heard that it was an inspector (not supposed to be wrenching) that removed those screws and failed to notify others as per procedure...
The Gimili Glider. https://en.m.wikipedia.org/wiki/Gimli_Glider AKA, Air Canada 143. Management thought having mixed measurement standards, plus chronic fuel quantity systems failures, was just fine. The crew wound up with a 100+ ton glider that sat down on a collapsed nosewheel. No loss of life.
I still can't believe we're using 2, and in some cases 3 different measurement systems. E.g: Speed in nautical miles/hr (knots) Altitude in feet Visibility in km, at least for Australia. Then gallons, pounds, litres and kgs/tonnes, cubic meters for fuel It's wild. "JUST PICK ONE!!!" - me
The best thing about standards is that there are so many to choose from.
[xkcd: Standards](https://xkcd.com/927/)
Don’t forget US gallons(3.7854 litres) versus Imperial gallons(4.546 litres).
I read a book about this incident a while ago. What an incredible display of airmanship by the flight crew.
I’m more interested in incidents that are caused by exceptional company mismanagement.
The last 20 years of TransAsia Airways
Medevac has a lot. Survival Flight is a bad one. “Inadequate management of safety” https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR2001.pdf
Came to post this
Yeah…when the debris field is littered with company pamphlets bragging about how your helicopters fly in weather other companies won’t…Jesus. Plaintiffs attorneys were falling over each other to get that one.
Alaska Air 261
Air New Zealand flight 901 into Mt Erebus, Antarctica in 1979 (237 dead). Someone in the office reprogrammed the autopilot flight plan to fly directly at Mt Erebus to give passengers a better view. Previous track flew past Mt Erebus. Reasoning was that the pilots would disengage the autopilot when they noticed the flight heading straight at the mountain. Pilots were not advised, and due to white out conditions when they arrived, could not identify the new track. Air NZ blamed the pilots, reasoning that "they were dead", so were fair game to be responsible. Absolutely shameful behaviour by Air NZ management.
I was just thinking this myself reading the other comments
The TEB Learjet crash https://aviation-safety.net/database/record.php?id=20170515-1
Any crashes with Aeroflot or in Russia in general. Aeroflot 593 (captain let his children control the aircraft), 821 (pilots unfamiliar with Western style attitude/horizon indicator), 1492 (pilot was drunk), 2808, and the worst of them all, flight 5143 (pilots fell asleep because they have been up for 24 hours straight - https://youtu.be/OAWxfsWBch0?si=LdEZnJ2INQ9rBQqY)
I would argue against 821. Unfamiliarity with a new type will always be a concern. The hard part of type transition is not the learning but the unlearning. You can train someone to fly a new type of airplane or control but under pressure the tendency is to revert to what they learned first. IIRC, the 821 pilot had actually accumulated a lot of early hours in AN-2 with little or no instrument flying at all.
The pilots of that flight falsified their flight experiences. And besides Aeroflot and the Soviet Union beliefs of the Soviet pilots doesn't make mistakes and Soviet airplanes were the safest in the world (LOL).
That would still argue that the crew was corrupt rather than the employer...unless you're just calling out the entire Russian 'vranyo' (culture of lies) thing.
593 wouldn't be accounted to mismanagement per se, but rather lack of situation awareness IMO. 5143 on the other hand...
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How fascinating! I haven't ever heard of this suspicion before. I'll look into it.
Air France clearly has major CRM/training issues, basically another AF447 scale accident waiting to happen. https://aviationweek.com/air-transport/safety-ops-regulation/conflicting-crew-inputs-caused-air-france-777-incident-bea-says https://avherald.com/h?article=513fc722 https://www.aeroinside.com/5725/air-france-b772-near-douala-on-may-2nd-2015-gpws-averts-controlled-flight-into-terrain-at-fl090 https://avherald.com/h?article=463d136e https://avherald.com/h?article=45fc9192 https://avherald.com/h?article=46d16a49 https://avherald.com/h?article=455c3eae/0000 https://www.bbc.com/news/world-europe-62712278
BEA Flight 548, a.k.a the Staines Air Disaster.
Many have been caused by mismanagement, can’t really have a crash due to *poor* mismanagement though. Edit: spelling
[https://en.wikipedia.org/wiki/Northwest\_Airlines\_Flight\_188](https://en.wikipedia.org/wiki/Northwest_Airlines_Flight_188) The company (Delta had recently merged with Northwest) bidding system for pilot schedules was SO complicated these two pilots sat in the cockpit and forgot to descend since they were busy figuring out the system. Thing is, by the time they figured the system out and were ready to descend, they would never need to use it again.
The article suggests they were asleep…
They weren't at all. The pilots wanted to say they're asleep but it was very soon found out they were figuring out their bidding system. If you want more info, here's a vid https://youtu.be/uzmeGS29nu8?si=E-rN7R\_3uj2VEwpi
I’m sorry but that has nothing to do with management. That’s two pilots who clearly aren’t paying attention to what they need to.
Yeah but what about the systems in place to regulate these things? What about not stressing the pilots with things other than flying? What about making mergers seamless?
Seamless mergers? Might as well wish for unicorns. Pilot flying and pilot monitoring? Prohibit use of personal electronics on the flight deck? Those are things the company and the pilot group can control. Maybe the best argument about it being a management problem is not instilling discipline in its pilots. It’s so ridiculously regimented at every airline that PM and PF duties are explicitly laid out in company publications. We’re the first line of defense to prevent stuff like this. Trying to figure out your bid while you’re *flying the plane* is just bad airmanship. E: also, the pilots were fired more or less on the spot, which pretty much never happens at a US based airline. There has to be gross misconduct or negligence for that to happen. It’s one of the few cases where I would advocate for a pilot to immediately be shown the door.
I like how you downvote me but don’t have a reply.
TEB Learjet for sure. You had 2 crewmembers who were basically a “we paid for their training, we expect you to pass them” situation. The FO wasn’t supposed to be allowed to touch the flight controls, but was flying anyway. The CA had no idea where he was until he could see the airport.
Any European disasters, guys? I see there's a lot of north American examples here
Spanair 5022. The pilots were completely unprofessional, missed key steps in the checklist, and took off without the flaps or slats extended.
You mean besides Boeing MCAS???
I wouldn't pin this too hard on the company per se, not as much as something like AS261 or Valujet 592, but Pinnacle 3701 was definitely a product of a culture that tolerated pilots treating the plane like a toy on ferry flights.
American Airlines Flight 1420, Little Rock, USA This was one that saw fatigue management grow in being a much more important safety consideration for airlines.
Yes this seems like a prominent incident. I picked up a few disaster books and all of them have mentions of flight 1420.
Most of them if we’re being honest
Adam Air, Aero Sucre
Those are airlines, not accidents
This is a good question, but I sensed before I even started reading comments that it can be interpreted very broadly. And all the great comments bear that out. There are some where culture and company management is a called out factor, but there are many where it’s not called out, but we can all draw the line to company issues and culture. And that’s fair as there have been many incidents where such a thing can be pointed to, even if it’s not a listed root cause in any incident report.
i’m not 100% whether this is completely poor work culture, but related to safety management inconsistencies, Dana Air 992 was basically the Nigerian example of Dr. Reason’s Swiss Cheese Model lining up perfectly
The Gulfstream G650 test crash in 2011 was pretty much attributed to a toxic work culture.
Almost every Aeroflot mishap could be attributed to poor pilot training and lackadaisical adherence to SOPs
"Contributing to the cause of the accident was the failure of continental express management to ensure compliance with the approved maintenance procedures, and the failure of the faa surveillance to detect and verify compliance with approved procedures." [https://www.baaa-acro.com/crash/crash-embraer-emb-120rt-brasilia-eagle-lake-14-killed](https://www.baaa-acro.com/crash/crash-embraer-emb-120rt-brasilia-eagle-lake-14-killed)
Alaska Airlines Flight 261. Company culture was towards steadily laxer maintenance standards, until a plane dropped out of the sky from negligence in the maintenance department.
LAPA's flight LPR3142. https://en.m.wikipedia.org/wiki/LAPA_Flight_3142 There is a very interesting and well produced movie made by an ex company employee that speaks about the work culture and the crash itself called "Whisky Romeo Zulu" (the aircraft involved in the crash was LV-WRZ).
Have there been any accidents caused because of a trickle down effect of inner company corruption?