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Old 7th Oct 2004, 06:30
  #61 (permalink)  
 
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MOR

It does seem a pity that you feel the need to try and discount me as a person (about whom you know absolutely nothing except that I live in New Zealand - every other factual thing you infer about me is incorrect) rather than just engage in the debate. I will not debase the important points that you make either by defending myself or attacking you.

I do not agree with you - or rather I think that you only deal with part of the matter.

If we are to learn from an accident investigation we must not only know what happened, but also why it happened. I'll make my point with the simplest possible example.

If a human error incident occurs and it is determined that the proximate cause was that the captain was fatigued and the FO felt unable to challenge the captan because that is the way things are in that company (and there are companies where that is the case), then we can fault both flight crew and invoke whatever sanctions we like, but we have done nothing to manage the underlying risk in most actual cases.

Your argument is valid if it turns out that the captain stayed up all night on his nightstop, and the FO has a personality defect. But even then there should be some follow on questions about selection and training.

But in most cases there will be systemic contributors to do with such things as rosters, organisational culture and so on. If we do not examine the underlying causes and, if necessary, correct them, then the disciplining of the actual flight crew achieves nothing.

It is simply out of touch with how humans perform tasks to assume that because you have lines of authority and comprehensive manuals that failure to adhere to them is solely a matter of individual competence. Your view is supported neither by psychology, organisational research or aviation accident statistics.

I have done work on why people do and do not use CHIRP and other anonymous reporting processes, and how the incident statistics are distorted by relying on such databases. It is fascinating that in some cases cultural assumptions are so embedded that even anonymous reporting processes are not trusted.
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Old 7th Oct 2004, 06:50
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Rongotai, I am glad you have the capacity to understand where a lot of my (and many others) frustration comes from. It is this "holier than thou" ATTITUDE that is so prevalent with MOR and others that is deplorable.

Keg, you seem to have no trouble taking the high moral ground when it suits you. I am sick to death of all this negative garbage being perpetrated in these forums. I, like you enjoy working for my airline. It sure as hell aint perfect, however in the 4 different airlines which I have worked (both here and Europe), they all had their good points and bad. You stated I know bugger all, that may be the case but as your collegue alluded to he was told how great he was (by your airline), and other friends of mine were told the same. I tried to state to the juniors and others, they should NOT believe this type of CR@P. It does NOT lend itself to a safer operating culture. I do not dislike you or your ilk, but i will never sit idly by while SOME of your collegues pour scorn over the remainder of the aviation community, (particularly Virgin). They are not qualified nor entitled to do so.

MOR, we all know the value of SOP's and don't need to be lectured. The fact you think we do is quite remarkable. Have you ever worked outside you current airline or are you a career cadet from the 80's? If you have been around as you say, you would well know the benefit of a non punitive reporting culture, and the associated merits in relation to sound team building priciples. In EVERY case I have studied, a relaxed, friendly and co-operative culture is far safer and more efficient than the "I know everything, we do it this way because we are the best attitude".

We ALL know about following SOP's,we ALL know about following the taxi line, we ALL know about not busting minimums, we ALL know about maintaining a disciplined and professional approach to the despatch of our duties.

I have worked in a gestapo type outfit where the pole is inserted firmly into the anal cavity. It is outdated neanderthal thinking which has NO place in todays modern environment.

Don't you think we could all do well to put this monotonous, negative diatribe to bed. Robust discussions are great and we can all learn plenty. Lecturing about professioalism to other professional pilot's is in my opinion not required.

Last edited by Sperm Bank; 7th Oct 2004 at 09:09.
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Old 7th Oct 2004, 07:27
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MOR

I would like to here why NZ is 20 years behind in human factors.

I would also like to know how you know this if you haven't actively been involved in NZ aviation for many years.

NO I'm not trying to bust your chops, it is a genuine question.

Also to everybody else: I thought that the 733 in question was being held in OZ until CASA did its thing. Cause today I noticed it was parked up in NZAA

Do CASA work 10 x faster than CAA or something


splat
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Old 7th Oct 2004, 07:42
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On Saturday.....
Vote 1..............Spermbank!

Love your work, great to see experience and commonsense making so much sense!
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Old 7th Oct 2004, 09:46
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Sperm, you seem to have perched youself on the moral high ground there too, matey. Buzz is right, with an attitude like that, you should be running on Saturday. Thats not a compliment, BTW.

I lost count of the times at Heathrow and CDG (Paris for you cadets) where the mighty Oz kangaroo took a wrong turn or didn't adhere to instructions...........then only make it worse by trying to BS their way out of it.
Your comments on page 3 of this thread, sir. Negative datribe? You seem to be able to give, but not take.

For this and many other reasons, I rest my case with regards to LCC's!
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Old 7th Oct 2004, 10:26
  #66 (permalink)  
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Rongotai

It does seem a pity that you feel the need to try and discount me as a person (about whom you know absolutely nothing except that I live in New Zealand - every other factual thing you infer about me is incorrect) rather than just engage in the debate.
I have no idea where you get that from - I had no intention of doing any such thing. I don't know how you intepret "I'm not entirely sure..." as an insult, but if you do feel insulted, you have my apologies - that was not the intent. I only mentioned it as some of the terminology you used suggested you weren't in the industry.

Anyway, I agree that I'm only looking at one part of it. I simply couldn't be bothered typing a ten page dissertation on the subject. I also agree with a lot of what you say, except this bit:

If we do not examine the underlying causes and, if necessary, correct them, then the disciplining of the actual flight crew achieves nothing.
I never suggested that it does; in fact, my view is that disciplining the crew is innapropriate except in cases of deliberate misconduct. Even then, the heavy-handed application of discipline will never solve the underlying problem, in fact it will probably exacerbate it. In any case, the more normal thing in most airlines I have had dealings with, would be a period of re-training in the sim, and it would be re-training, not a punishment (I know, I used to carry such re-training out).

In the airlines I have worked for, the likely outcome for the crew in the incident this thread refers to would be a slap on the wrist, a stern "don't do it again", and back on the roster poste-haste. No big deal at all.

It is simply out of touch with how humans perform tasks to assume that because you have lines of authority and comprehensive manuals that failure to adhere to them is solely a matter of individual competence. Your view is supported neither by psychology, organisational research or aviation accident statistics.
Adherence to procedures has nothing to do with competence, and everything to do with self-discipline. However, I would point out that the underlying philosophy of the NZ CAA leans heavily on the idea that their responsibility extends solely to ensuring that company manuals are up to date, and assumes that the company and the individuals will then always comply with them. At least that is what they told me when offering me an FOI job a few years ago (I didn't take it). A very odd compliance culture.

BTW if you are going to suggest that my views are not supported by "psychology, organisational research or aviation accident statistics", perhaps you could indicate what you refer to - I would genuinely like to know where you get those ideas from. Many of my views come from material supplied to me when doing a core TRI course in Europe, which, as it is endorsed by the UK CAA, I assumed I could rely on.

It is fascinating that in some cases cultural assumptions are so embedded that even anonymous reporting processes are not trusted.
Examples?

splatgothebugs

In my last job I was in check and training. In JAA land, CRM is assessable on each competency check (ie you could fail the check on CRM). I don't see that over here. Also, there are established courses there such as MCC which don't seem to happen here. A recent type conversion course I did here in NZ had zero CRM/HF content, whereas it would have had a significant element in Euroland. Finally, a few chats with ex-instructor mates from the old days, who are now in the airlines, indicates to me that CRM/HF is given a far lower profile over here.

If you think differently, please tell me as I don't profess to have a complete picture of this area (yet).

As for buzzy and the rest, if you have nothing useful to contribute, why not take you talents to Jet Blast...

Last edited by MOR; 7th Oct 2004 at 10:42.
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Old 7th Oct 2004, 11:39
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MOR and quim,
you blokes had better hope that CRM doesnt start getting assessed in OZ!
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Old 7th Oct 2004, 11:49
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you blokes had better hope that CRM doesnt start getting assessed in OZ
Coming sooner than you think!
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Old 7th Oct 2004, 11:54
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Capt Fathom,
understand that CRM assessment is well on its way in Australia, do you have any detail with regard to when this is to be introduced?
Thanks Buzzy...
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Old 7th Oct 2004, 19:11
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I get along with my own lot just fine, buzzy. Its you sc@bs that I have a problem with.....
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Old 7th Oct 2004, 21:27
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quim. Are you high?
Some real issues going on in that psychometrically correct head of yours.
Fortunately, I happen to know that the vast majority of your colleagues are wonderful people, it does surprise me a little though that none of them have expressed their embarassment of you and asked you to shut up.

Last edited by Mr.Buzzy; 7th Oct 2004 at 22:57.
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Old 7th Oct 2004, 23:54
  #72 (permalink)  
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buzzy
you blokes had better hope that CRM doesnt start getting assessed in OZ!
As I am an accredited JAA CRM instructor, and as that qualification transfers to Oz under CASA rules... YOU had better hope that CRM doesn't start getting assessed in OZ!
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Old 8th Oct 2004, 00:46
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MOR

I stand corrected on HF.

splat
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Old 8th Oct 2004, 01:14
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MOR

"in fact, my view is that disciplining the crew is innapropriate except in cases of deliberate misconduct. Even then, the heavy-handed application of discipline will never solve the underlying problem".

Agreed - provided that you also accept that there may be systemic causes or contributing factors to human error commited by an individual. But on the face of it your point here seems to be at odds with what seemed to be a linear dependence on the command structure and SOP's.

" In any case, the more normal thing in most airlines I have had dealings with, would be a period of re-training in the sim, and it would be re-training, not a punishment (I know, I used to carry such re-training out)."

The trouble here is that I too often see this:

(a) being regarded as the only intervention necessary (which locates the 'problem' exclusively with the individual); or

(b) being believed as having been remedied by re-training when the error was in fact a one off situationally triggered mistake that is unlikely to re-occur, and which anyway has already led to agonised self appraisal by the pilot concerned.

That is not to say that the cause does not sometimes lie within the skin of the individual.

" Adherence to procedures has nothing to do with competence, and everything to do with self-discipline."

Often, maybe even usually, but far from always. It sometimes has to do with cognitive overload, unrecognised patterns, or perceptual distortions that have situational origins rather than origins to do with psychological or physical limitations of the individual.

" However, I would point out that the underlying philosophy of the NZ CAA leans heavily on the idea that their responsibility extends solely to ensuring that company manuals are up to date, and assumes that the company and the individuals will then always comply with them. At least that is what they told me when offering me an FOI job a few years ago (I didn't take it). A very odd compliance culture."

I fully agree. That is why my work is now entirely in Europe and the USA. Why do I still live here? Lifestyle, and my clients are happy to pay my fares.

" if you are going to suggest that my views are not supported by "psychology, organisational research or aviation accident statistics", perhaps you could indicate what you refer to ".

I was drawing on what you wrote in your earlier posts. You seem to have expanded on what you believe in your most recent post, and that has removed some of the reasons for that critique. However - on the basis of what you have written so far - I still have the following concerns:

(a) on a flight deck (more than in any other workplace in any industry in my view) good training, clear lines of command, SOP's and self discipline are necessary but not sufficient conditions for optimal safe operations. Emotional and physical well being is also required. It is now well over 25 years since the measurement of various of these effects on human performance has been demonstrated and measured. In my view risk management of these factors should be about 30% down to individual professionalism and about 70% to organisational management (provided that licensing, selection and initial training are robust. I personally agree with you that there are good reasons for concern about the first of these in NZ, if not Oz). The actual focus of effort is about the exact reverse proportion:

b) as flight management technology becomes increasingly sophisticated emphasis on flight manuals and SOPs increases, and thereby an increasing focus on adherence to procedures ahead of basic airmanship. A consequence is that aircrew experience is increasingly characterised by intense periods of concentration alternating with periods of very low workloads (although this is not the case in operations such as European and NE USA short haul). The inevitable penalty of this is an increase in attentional lapses, especially during taxiing (the origin of this thread), take off and appraoch and landing. This is well researched, notably in France, and is resulting in 'fewer critical incidents but a greater proportion of them leading to accidents.

Your final point - examples of lack of trust of anonymous reporting procedures are by their very nature hard to come across. When we tried to document it by interviewing UK pilots in known incidents that did not appear in CHIRP all we achieved was to increase the mistrust, so we had to give it away. So I'll have to concede that it is an unproven statement.

You also replied to spllatterbugs:

" In my last job I was in check and training. In JAA land, CRM is assessable on each competency check (ie you could fail the check on CRM). I don't see that over here. Also, there are established courses there such as MCC which don't seem to happen here. A recent type conversion course I did here in NZ had zero CRM/HF content, whereas it would have had a significant element in Euroland. Finally, a few chats with ex-instructor mates from the old days, who are now in the airlines, indicates to me that CRM/HF is given a far lower profile over here. "

I entirely agree with that. But I am disturbed that recent changes by the FAA suggest a drawing back from CRM in Norht America.
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Old 8th Oct 2004, 02:21
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Agreed MOR. I'll be hoping along with many of your colleagues that you wont be wearing any of those impressive hats here in OZ.
Must you find it so important to validate yourself by telling us all about "When I was this, when I was that"....blah blah blah.

This is all about a taxy incident, most of us are humble enough to concede that this sort of thing can happen to us all. PERIOD!

You somehow manage to claim immunity by attempting to intimidate with your hat collection. Surely the last 4 or 5 pages of this thread have made you check yourself. Do you still think "It could never happen to me?"

Last edited by Mr.Buzzy; 8th Oct 2004 at 02:40.
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Old 8th Oct 2004, 03:15
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buzzy

If you can't understand the rationale behind establishing ones credentials when discussing this type of subject, you have little understanding of how professional people (doctors, lawyers, whatever) discuss things. It is to do with the credibility of the argument, not some form of idle boasting.

Now off you go to JB, which is clearly more your level.

Rongotai

Coming back at you later.

One quick question though: are you, or have you been, an airline pilot? Simple question, no hidden inferences or attempts at denigration, and no insult intended.
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Old 8th Oct 2004, 04:08
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Rongotai

OK here we go then.

But on the face of it your point here seems to be at odds with what seemed to be a linear dependence on the command structure and SOP's.
I wasn't so much talking about the rationale in the cockpit, as the legal framework under which the apportioning of blame, and the quest for compensation, works.

The command structure and SOPs are never going to solve the problem of human error in the cockpit, obviously - they are only as good as the weakest link, in this case the pilots. However they are the best framework we currently have for minimising risk. The "command gradient" is itself of little use, except where executive decisions have to be made. We always viewed the two people up front as the Captain and the Captain in Training.

(a) being regarded as the only intervention necessary (which locates the 'problem' exclusively with the individual); or (b) being believed as having been remedied by re-training when the error was in fact a one off situationally triggered mistake that is unlikely to re-occur, and which anyway has already led to agonised self appraisal by the pilot concerned.
I quite agree, and in fact part of the exercise for me was try and find out the background to the error. It was usually something like life stress or some sort of relational problem. We offered counselling where appropriate.

Often, maybe even usually, but far from always. It sometimes has to do with cognitive overload, unrecognised patterns, or perceptual distortions that have situational origins rather than origins to do with psychological or physical limitations of the individual.
I agree, however these factors aren't really a competence issue either. Someone who is unable to complete a procedure for the reasons above is not incompetent. They are basically overloaded with factors outside their skill set.

In my view risk management of these factors should be about 30% down to individual professionalism and about 70% to organisational management
I agree, but try persuading the airlines!

When we tried to document it by interviewing UK pilots in known incidents that did not appear in CHIRP all we achieved was to increase the mistrust, so we had to give it away. So I'll have to concede that it is an unproven statement.
That is a pity. I thought maybe you had tapped into something from the studies undertaken in some of the Far Eastern carriers, where any form of reporting is officially encouraged, but culturally discouraged.

An example- I was doing some training at Prestwick many years ago, and there were a bunch of Japanese pilots there being type-rated on the Jetstream 31. They had a habit of simply firewalling the thrust levers on takeoff, which is not a good idea as if the limiting system fails, you can overtemp/overtorque the engines. They were told time and time again to just set the required thrust, and did so on their final checks.

They get back to Japan, into a shiny new J31 with only delivery miles on it, and take off on a shakedown flight. Now away from the gaze of the instructors, they simply firewalled the thrust levers. Both engines expired at about 200 feet, and they were lucky to be over the runway and able to re-land. The engines were scrap. The bill was over NZ$7 million.

Why? A senior pilot did it, so they all did it too. The senior pilot was regarded as far more authoritative than all the British instructors...

Anyway, it seems we are in broad agreement. It is a very interesting subject, the more I learn the more interesting it becomes.
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Old 8th Oct 2004, 04:19
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Raw Data

No, never an airline pilot. I held a CPL and an IR, and I am not current with either. I am a systems safety professional, not an aviation professional.
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Old 8th Oct 2004, 04:57
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OK in which case my question is, do you find that in the area of Human Factors, aviation relates well to other industries? For example, train drivers, ship's captains etc.

On a visit back to NZ, I had the opportunity to visit the bridge of the Cook Strait ferry. It had more automation than the aircraft I fly (better seats, too, and the ability to go for a brisk jog around the bridge if you get restless).

I am wondering if the role of the ships captain has ever been compared with that of an aircraft captain? From a Human Factors standpoint.
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Old 8th Oct 2004, 07:50
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There are an increasing number of industries that are begining to "Wake Up" to the Human factors culture. Train drivers and Ships Crew are some examples. Hospitals are now begining to undertake their own Human Factor studies modelled on those conducted in Aviation.
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