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

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:

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... 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. Actually it is so on the nose it could be mistaken for a lump of King Island Blue!

Kharon

Still laughing.

Still confused; as usual. lots of shouting but not much traction.

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

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.

Up-into-the-air

Well Crikey goes again with the information flow.

http://www.pprune.org/dg-p-reporting...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. Chuss.

Lester Burnham

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

blackhand

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?"

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!

pps left yourself open there blackie!

Up-into-the-air

As I said BH:

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

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.

Well 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.