casa and the Reason Model

[Up-into-the-air]

The "Reason Model" has just been quoted in a Sydney Morning Herald article, regarding the "Jet into Water" incident, but deserves a better airing than being just hidden away.

The Model, otherwise known as the "Swiss Cheese" model, is about the times that when something goes wrong, usually it usually has a number of friends to help the first problem become larger.

The following puts the rationale well:

Swiss cheese model - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Swiss_cheese_model)

The recent Brazillia report into the Darwin "accident" demonstrates this wel, but casa and ATSB fail to use this to demonstrate EFATO issues or the underlying problems that can quickly escalate, rather saying ".......the operator has implemented simulator training ..........".

The challenge today is:

Can you give some really good examples of the "Reason Model" occurring in an aircraft accident over the past 20 years???

[Aimpoint]

The Airtex Metro into Botany Bay a few years back.

Classic example that fits into the Reason model - organisational influences and unsafe supervision allegedly resulting in preconditions then ultimately an unsafe act once the active failure occurred.

Not sure if this one is still before the courts - nothing else to say...:oh: The ATSB report could let you draw up potential associations though.

U-I-T-A, you're not fishing for answers to a university discussion board contribution are you...?

[QFF]

A tad over 20 years ago (1989) but the Kegworth crash of the British Midland 737-400 would be another example of James Reason's Swiss Cheese model - shutting down the wrong engine, skipper interrupted by R/T during post-shutdown review & didn't continue, vibration gauges ignored etc.

[Capn Bloggs]

I would have thought the "really good examples" would every prang that either wrecked the aeroplane or killed or maimed somebody.

[Icarus53]

You don't really need an accident to demonstrate the Reason Model - the fact that an accident didn't occur in serious circumstances can also be linked to organisational, workplace, team and personal failures that were otherwise defended by one of the other layers.

The (relatively) recent series of QF incidents (QF 32, 70 etc) demonstrate one or many "holes in the swiss cheese" which were ultimately defended at another layer. Apply the same logic to any number of near misses - anything that could have resulted in a hull loss - and you've got thousands of examples every single day.

I doubt very much Professor Reason wanted his model to be used just to explain accidents. The whole point is to assist in identifying active/latent failures at any level.

[T28D]

CASA actually use the Prosecute Model, it differs a lot from the reason model.

[Sarcs]

The Lockhart River accident is probably Oz's biggest lump of smelly (and by now very mouldy) Swiss cheese.:ugh: Actually it is so on the nose it could be mistaken for a lump of King Island Blue!:rolleyes:

[Kharon]

T 28 - CASA actually use the Prosecute Model, it differs a lot from the reason model. Still laughing. :D:D

UITA - The "Reason Model" has just been quoted in a Sydney Morning Herald article. Still confused; as usual. lots of shouting but not much traction. http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/confused.gif

And; then the No Reason model is used as an aid to administrative castration for the embarrassing little moments when the facts don't quite fit; despite strenuous denials of any obligation to the public for responsibility to "it". Nice one if you can make it work.

P.S. Has Doc Voodoo set his departure date yet or, is he still trying to extricate sensitive parts of his anatomy from the blender before leaving the sinking relic.

Strewth - AUD 00.20.

[gobbledock]

The Reason Model can be applied to almost every significant accident. The holes line up as each layer of defense is removed. Regulations in themselves should be a defense, but as in the case of Lockhart they actually contributed to some extra holes. That does happen at times, often latent conditions exist.
Unfortunately Reason's model is open for dissection by any bureaucrat with too much office time on their hands. In recent years some have pulled his model apart and even Reason himself at one stage cast some doubt on his own model, however intellects do tend to do this at times.

Kharon, Doc Voodoo won't be going anywhere to soon. He will want to at least debunk James Reasons theories on accident causation before he departs our already tattered industry. You know what these 'so called' intellects are like, too much time on their tax payer funded hands in which they can practice postulating, pulling apart tried and tested successful systems, hypothesizing, fantasizing and other forms of general assclownery.
Besides, Doc Voodoo is the bureaucrat in waiting to sit in the big chair whennit is finally agreed that the 'Angry Man' is the weakest link and it's time for goodbye.

[Kharon]

GD - Besides, Doc Voodoo is the bureaucrat in waiting to sit in the big chair when it is finally agreed that the 'Angry Man' is the weakest link and it's time for goodbye. I'll have a Coops on that, 2 as a matter of fact.

Tailwheel prohibits further 'Orse races. No further comment. However, a form guide to the big race could be cunningly instituted, perhaps with some SP odds for the star mounts. We shall see. (Silent prayer to the Horse God).

Informed commentators are tipping "Voodoo Hoodoo" as a rank outsider after an abysmal performance in the last Golden West Mafia Cup.

Inside information is that "He who must be named" has not been invited to race due a flunked anger management course, imposed by the Stewards after several warnings to his handlers and a shortage of willing jockeys.

I know Tail Wheel, I'll take it down. Devil made me do it, sometimes I just can't quite resist the temptations fate offers me. Mea Culpa.:D :D

[Up-into-the-air]

Well Crikey goes again with the information flow.

http://www.pprune.org/dg-p-reporting-points/482162-swiss-cheese-asa-style.html

AirServices now has it's own contribution!!

Maybe Kharon - more Hoodoo Voodoo to come??

I wonder if ATSB has a version??

[Kharon]

Get in quick with a candidate - Nearly all the cool names are gone – Voodoo Hoodoo, Master of Mirrors, Smoke Generator, Spin City Sister, Cruella De' Ville, Mumbo Jumbo, Cowl Clown, Fat City and the Great White Wimp.

There's really only a couple spare – Jiggery Pokery, Golan Heights or perhaps at pinch we could accept Weekly Wuzzit or Chamber Pot.

I hear the only short price starters are from West of the Dig Tree, so it's a tight field. You can find the venue on any out of date WAC chart.

SP on the PM network.http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/thumbs.gif Chuss.

[Lester Burnham]

This is actually harder to follow than when a PNG thread degenerates into an exchange of pidgin English !

[blackhand]

This is actually harder to follow than when a PNG thread degenerates into an exchange of pidgin English !
And makes as much sense.

[Up-into-the-air]

Well BH, lets get this back on track and look at two recent ATSB investigated "incidents".

One the Brassilia in Darwin, with two lives lost in some 20 odd seconds with an EFATO.

No attempt by ATSB to put the bigger picture of EFATO, FOI's and SOP's.

A crash Mr. casa, another two dead - Enough holes in this one

Then, the report this week on the non-sterile cokpit and a 220 seat jet with lots of warnings going off, but lack of proper responses to them by the pilots at the correct times.

LUCKY Mr. casa - No crash, not quite enough "holes"

[blackhand]

@up into the air
I understand that you disagree with ATSB and you need someone to blame other than the pilot(s), [may their souls rest in peace]
My reading of the ATSB reports indicate that both cases were down to the individual pilots' actions and not organisational or regulatory issues.

[Sarcs]

Geez Blackie sounds like the safety watchdog and regulator should employ your good services. Investigations could be wrapped up in a day with your fountain of wisdom and expertise...BH: " Ahh it was just the silly bloody pilots fault....nothing to see here!... Now let me get back to the Weigh Inn with two Hanuabada hand maidens, it was the Skull's shout wasn't it?":E

ps Blackie don't worry about the tab on the hand maiden's either...old mate skull's got it covered...oink..oink and GD tick tock indeed!:O

pps left yourself open there blackie!:ok:

[Up-into-the-air]

As I said BH:

No attempt by ATSB to put the bigger picture of EFATO, FOI's and SOP's.The basis of the ATSB report was to say that the operator now uses simulators. This is perfectly true, but an enormous opportunity to put a basis together to deal with the above issues was missed.

As you are aware, pprune posts routinely go to these issues and need a precise way forward as regards use of simulators.

The case in point of the EFATO at Camden of the PA30 should be considered here. This case was in clear breach of the Pilots Operating Handbook [POH], which calls for such maneuvers to be undertaken at a minimum altitude of 5000FT.

Please explain Mr. Blackhand [sorry casa???]

[blackhand]

but an enormous opportunity to put a basis together to deal with the above issues was missed.

That's an interesting idea, and perhaps could be explored further.
Although one would assume that EFATO would be covered in SOPs already.
As for FOIs, you appear to have issues that perhaps don't need exploring any further.

Now let me get back to the Grand, it was the Skull's shout wasn't it?"http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/evil.gifWell off you go then, I'm busy at the Weigh Inn with two Hanuabada hand maidens at the moment, Ah SP Lager.

[gobbledock]

The Darwin field office oversight of this operator would be an interesting read. Would like to see previous audit reports and surveillance reports of the flight operations of this operator also. And Fort Fumble moved pretty quickly anyway and saved the bacon of the Darwin field office manager 'just in case', by moving him into a more senior role within Fort Fumble, and he is now based in Brisbane.

I think Blackhands admiration of The Skull is putting him in good steed to become a future AWI. Good work.


Tick tick again, indeed.

[Frank Arouet]

hand maidens

Speaking of which, has this got something to do with your hand injury?

Mrs Palmer again I suspect.

[Kharon]

Icarus 53: I doubt very much Professor Reason wanted his model to be used just to explain accidents. The whole point is to assist in identifying active/latent failures at any level. This post presents arguably one of the most intelligent statements I've had the pleasure of reading. The 'reason' for Reasons model was to prevent the 'holes' from lining up.

It's one of the few reasons for accepting Safety Management Systems (ala Oz) i.e. Here is hole, let's plug the the little bugger up, - job done; then come audit time there is an elegant statement and a “Gold star” for documented, active, effective safety management. The 'system' may have eliminated a potential threat. Bravo.

There now, a (dare I say it) a reasoned debate on accident prevention seems like a good cause to me; all things considered.

[Sarcs]

I doubt very much Professor Reason wanted his model to be used just to explain accidents.

The reason model is constantly mis-interpreted as such, the UNSW have a good article here: http://www.aviation.unsw.edu.au/about/articles/swisscheese.html It is interesting that the article starts with this paragraph: When it comes to understanding incidents and accidents, James Reason’s ‘Swiss cheese model’ has become the de facto template. This has had a positive effect on aviation safety thinking and investigation, shifting the end-points of accident investigations from a ‘pilot error’ explanation to organisational explanations. However, overzealous implementation of a theoretical framework has led to an illusion of management responsibility for all errors. The ‘Swiss cheese model’ of accident causation is now adopted as the model for investigation in many industries. Indeed, in aviation it has become the accepted standard as endorsed by organisations such as the Australian Transport Safety Bureau (ATSB) and the International Civil Aviation Organisation. The Swiss cheese model shows several layers between management decision making and accidents and incidents.

The noticeable missing link is the regulator, is this a mistake or does it reflect the current philosophy or belief of the regulator??:hmm:

Hope you don't mind K, copied this across as I felt your thread deserved better than being merged into the FRMS debate...:{


Tick tock.
Plane Talking - Ben Sandilands - Jetstar (http://blogs.crikey.com.au/planetalking/2012/04/23/jetstar-acts-over-unsafe-landing-approaches/)

Quote:
The document could be read as confirmation of strong safety action by the airline, yet also as confirmation that it has for years been less safe than desirable, and, by inference, inadequately overseen by CASA, the body that grounded its smaller competitor Tiger, as an imminent risk to public safety.
Ministerial selective vision and hearing, Senate meek acceptance of 'expert' opinion, Airline executive pony pooh, CASA spin polished arse cover, ATSB weak sister platitude or fit aircrew bleating about being tired can not be used any longer as an excuse.

Someone's going to get hurt.

Sarcs

Sheesh..FFS.....and how long has 'stabilised approach criteria' been around..must be twenty years or more??:ugh:

http://flightsafety.org/files/alar_bn7-1stablizedappr.pdf

It could be argued, that the reason model was responsible for the establishment of the 'stabilised approach criteria'!:D

[Kharon]

Sarcs - Hope you don't mind K, copied this across as I felt your thread deserved better than being merged into the FRMS debate. http://images.ibsrv.net/ibsrv/res/src:www.pprune.org/get/images/smilies/thumbs.gif
Not at all, but I do appreciate the courtesy; and, yes being 'flicked' into an endless, pointless debate about 'tired' pilots is, without doubt, dreary.

However, (al'a Churchill) all is not lost; whilst the silly buggers are roaring and squabbling over who is the tired one; we, shall sit quietly and look at Doc Reasons cheese, just for fun.

Join the dots is the name of the game - join the dots and see the picture; and what a grim picture it is, with no one left to blame ('ceptin them what's dead). Wuzzn't uz - we have ticks see - ticks, everywhere. Glad it's not my dog -

Couldn't it possibly be that both the cause and prevention of accidents is a team deal ??. Probably not according to current spin.

Selah.

[Stasi Hunter]

[QUOTE][The noticeable missing link is the regulator, is this a mistake or does it reflect the current philosophy or belief of the regulator??/QUOTE]

In its ever PROACTIVE manner the CASA is certainly part of the Reason Model. However instead of Swiss cheese CASA employs ordinary sliced Coon cheese. It then aligns the holes by the simple application of an apple corer. It can then ProActively take the necessary action to take another criminal operator out of the system, this even before the event. This application has worked successfully in G.A. And if not for lactose intolerance would work for the Airlines as well. Apparently Tiger is not so intolerant.

SH

[Kharon]

Sarcs - The noticeable missing link is the regulator, is this a mistake or does it reflect the current philosophy or belief of the regulator??.


Not so – just look for a conga line, all dressed in the latest hi viz burqa whistling their merry way out of the car park doorway. Easy to see. For the visualy impaired the fumes from fine wine, big cigars and gourmet coffee should assist. :D

[Sarcs]

Oh where is Sour Kraut when you need him?? A Barvarian flavoured pint would go down well right about now!:ok:

[Up-into-the-air]

Did you see:

Notice of Final Rule Making: released on Monday 21st May 2012

Senate hearing 23rd May 2012

Well Mr. caa [casa]

NFRM 1007OS - Mandatory Flight Simulator Training – Amendments to Civil Aviation Orders (CAOs) 40.1.0, 40.3.0 and 82.0

Background

In July 2009, the Australian Transport Safety Bureau (ATSB) released a Transport Safety Report on a serious incident involving an Embraer EMB-120ER Brasilia aircraft, registered VH XUE, which occurred at Jundee Airstrip, Western Australia on 26 June 2007. The serious incident involved a mishandled go-around caused by the flight crew's failure to recognise the loss of power of one of the aircraft's two engines.

The Report identified that "there was no regulatory requirement for simulator training in Australia". A formal ATSB safety recommendation (AO-2007-017-SR-084) was made to CASA recommending that CASA address this safety issue.

In September 2009, CASA initiated a project to review its regulations and investigate the need to mandate the use of simulators for certain flight crew training requirements in the air transport sector and other sectors where this may be considered appropriate.

The first phase of this project involved the canvassing of options in a DP that would introduce a requirement for certain operators to conduct simulator training. This consultation, which was conducted between December 2009 and February 2010, raised two main points of interest:

Most respondents were of the view that all training and checking exercises that were of a high-risk nature should not be conducted in an actual aircraft, while some respondents suggested that all training and checking, regardless of whether it is high-risk or not, should be undertaken in a flight simulator.

It was evident that a graduated approach, depending on the aircraft's size, and giving due consideration to the availability of flight simulators, would be the preferred way of dealing with this issue.

The issue of simulator training again came to a head following an aircraft accident which occurred on 22 March 2010 at Darwin Aerodrome, Northern Territory where an Embraer EMB-120ER Brasilia, registered VH-ANB, crashed shortly after take off on a training flight. Both pilots on board were killed in the accident.

The ATSB Report2 into this accident revealed that the flight involved a simulated engine failure after take-off. This particular exercise, however, was conducted in a way which simulated a simultaneous engine failure and propeller autofeather failure—a considerably more challenging exercise—which is not recommended or approved by CASA. It is not known whether the check pilot (the pilot-in-command (PIC) of the aircraft) initiated this type of exercise deliberately or inadvertently. Notably, it emerged that the PIC "was selected as a simulator instructor as part of the operator's transition to simulator training for its EMB-120 crews. During simulator training in February 2010 for the renewal of his command instrument rating, the PIC demonstrated proficiency in handling engine failures on takeoff."

On 27 October 2010, CASA published NPRM 1007OS for comment, which contained proposed rules for a graduated approach to mandate the use of flight simulators and FTDs for non-normal aircraft exercises.

The NPRM put forward four key change proposals:

For aeroplanes and helicopters certificated to carry 20 or more passengers, or with a maximum take-off weight (MTOW) of greater than 8,618 kg, and where an appropriately qualified flight simulator or FTD is available in Australia or overseas, any non-normal exercise must not be performed in the actual aircraft.
For multi-engine aeroplanes and helicopters certificated to carry between 10 and 19 passengers, and where an appropriately qualified flight simulator or FTD is available in Australia, any non-normal exercise must not be performed in the actual aircraft.
Define 'non-normal exercise' as an aircraft operation for flight crew training, checking or testing, which involves a simulated system failure of a kind that affects, or would be likely to affect, the flying performance or handling characteristics of the aircraft beyond the parameters of normal operation.
Provide appropriate relief where a flight simulator or FTD is only commissioned at short notice.

Comments to NPRM 1007OS closed on 21 January 2011, after which CASA reviewed all responses, revised the proposal, undertook regulatory impact assessments, undertook further consultation with respondents to the NPRM and developed the final rule.

1 ATSB Report AO-2007-017
2 ATSB Report AO-2010-019Is this really the view of all casa's FOI's

[Up-into-the-air]

Probably worth re-visiting some of the issues canvassed earlier this year and remind us of the cases that reflect the Reason model.

atsb certainly does not comply with this in their latest Senate offering.

Ben Sandilands is on to this:

ATSB 'leads' air safety into a retreat from Reason? | Plane Talking (http://blogs.crikey.com.au/planetalking/2012/11/26/atsb-leads-air-safety-into-a-retreat-from-reason/#)

Well, well Mr. atsb - How can you jump away from this "again".