I 'tuned in' to the AOPA Panel discussion on Facebook that included the new CASA PMO, Dr Kate Manderson, on the evening of 13 October 21. I think Dr Manderson is around the fifth or sixth CASA PMO (however described) since I started flying in the mid-80s. Dr Manderson deserves genuine thanks for dedicating time to participating in the discussion, during what must be an extra busy time for her.
The discussion about "risk appetite" and "risk settings" and "what are we OK with?" are a manifestation of a fundamental and chronic problem in CASA. The problem has been acute in CASA Avmed for some time.
What the standard isn’t and what weight isn’t put on a PMO’s strongly-held opinion
The standard is
not what CASA wakes up each day and decides it’s 'OK with' based upon strongly-held subjective opinions, no matter how ‘expert’. Unfortunately, CASA has been encouraged to
believe the standard is whatever CASA decides it is, because CASA has been left to its own devices to create a regulatory regime that is now so complex and convoluted that challenging anything CASA does is prohibitively dangerous for the financial health of most individuals and, in some cases, for their physical and mental health. That has produced what systems safety experts and aviators call: normalised deviation.
One of Dr Manderson’s predecessors found out, the hard way, about the worth of his strongly-held subjective opinions, in ascertaining a pilot’s compliance with the legislated medical standard. The Tribunal Member in
this 2013 AAT matter understood the law and put the then PMO in his place:
[I]t could not be plainer that Dr Navathe is an advocate for his own decision. I do not propose to have any regard to his opinions. For the future I would trust that CASA’s Legal Branch would exercise independent judgement in deciding what witnesses ought be relied upon and the content of their statements. They ought, obviously enough, be confined to matters that are relevant and witnesses ought be those who can truly provide an independent opinion.
A cultural problem
The Tribunal’s trust was misplaced. That’s the nature of the Avmed beast these days. Avmed does not make mistakes; everyone else does. That’s why I didn’t say Dr Navathe ‘learnt’ the hard way.
I wrote to the recently appointed CASA CEO/DAS to invite her to arrange for removal of a few sentences from the DAME Handbook manifesting systemic unlawful behaviour that CASA has acknowledged as such. Just a few sentences.
The CASA response was the sadly-typical specious sophistry in defence of changing nothing. That is because the unlawful behaviour I identified continued after it was addressed only in my case and only because I commenced AAT proceedings the first time I was subjected to it, then threatened AAT proceedings the second time.
It’s analogous to ‘robo-debt’: Deal with the rare individuals who have the temerity to challenge our unlawful behaviour and shut them down before a potentially embarrassing AAT decision, but continue with the practice as a general rule. It’s all in the interests of hunting down and crushing dole bludgers, welfare fraudsters and the aviation-equivalent - pilots with ‘conditions’ - when the agency’s compliance with the law would get in the way of achieving the noble cause.
The simple and very telling test is this: When, in recent history, has any CASA Avmed doctor said: “I made a mistake. I apologise to you for my mistake.”?
When CASA acknowledged that it could not lawfully place the purported restriction: “For CASA audit” on my medical certificate, did the person responsible for that unlawful behaviour say: “Sorry. I did not realise that this could not lawfully be done. It will not happen again.”? Nope. That’s why it happened again and I had to threaten AAT proceedings again.
And this a simple example that could and should be easily rectified by any organisation with even a modicum of corporate competence and integrity. Try getting CASA Avmed to understand and accept that they cannot lawfully refuse to consider evidence and make a decision as to a person’s medical fitness during some arbitrary period CASA Avmed plucks out of wherever. In the most recent AAT matter in which I was involved – resolved in my favour – the Tribunal had to ‘pull up’ the Avmed doctor with a strongly-held subjective opinion on the issue and remind him of what the law actually requires. Any apology to me? Nope.
Submission #56 to the current Senate Committee inquiry into the general aviation industry, by a DAME, details appalling behaviour on CASA Avmed’s behalf. In one case CASA Avmed made a patent mathematical mistake and concluded that the medical certificate applicant had a hair test that was positive to methamphetamine. The applicant was also accused of being an “unreliable historian”, which is ‘Avmed-speak’ for “liar”. The DAME states, after having described just two cases of many of which he has first-hand knowledge:
As a medical practitioner, I can accept that people make mistakes, but these cases are not mistakes, these are instances where AvMed doctors have brutalised individuals, for no particular gain, except the theoretical “safety of air navigation”, which on review, was never compromised.
Do you reckon there was any acknowledgement of the nature of or apology for this behaviour by CASA Avmed?
If a private medical practitioner behaved in the ways described by the DAME in these cases, the practitioner’s indemnity insurer would be writing cheques and their cover would eventually be withdrawn. If I were subjected to it by a private medical practitioner, I would be instructing lawyers to commence legal proceedings for damages.
These are manifestations of a cultural problem. Google: “Why Certain People Will Never Admit They Were Wrong”. This passage resonated for me:
[W]hen people are constitutionally unable to admit they’re wrong, when they cannot tolerate the very notion that they are capable of mistakes, it is because they suffer from an ego so fragile that they cannot sulk and get over it — they need to warp their very perception of reality and challenge obvious facts in order to defend their not being wrong in the first place.
Hands up who’d be happy to board an aircraft whose pilot in command could not tolerate the very notion that he or she is capable of making mistakes? Count me ‘out’ as a passenger!
We all make mistakes. On a flight the other day I realised I had not latched the aircraft’s canopy properly. Insufficient attention to proper checklist actions. A few flight reviews ago the ATO picked up the fact that I had not ‘signed off’ the daily inspection for my aircraft. I had conducted the inspection but forgot to endorse the maintenance release. Too focused on other aspects of preparation for a flight review. During the landing roll nearing the end of a flight review while I was the CASA General Manager of General Aviation Operations, I mistook the undercarriage control for the flap control, both of which were obscured by the dual control arm of the aircraft. Take it from me: undercarriage retraction during the landing roll is expensive and embarrassing! (Fortunately, I haven’t made that mistake again and the aircraft was repaired to fly another day. I went on to be part-owner of it for a while and was pleased to see it the other day, still going strong.)
CASA Avmed makes mistakes, too. But try finding any evidence that they’ve ever acknowledged or apologised for one.
A little glimpse through the CASA Avmed looking glass
Think about the mindset that creates forms
like this, requiring instructors to be informants on student pilots. One of the behaviours CASA Avmed wants instructors to inform on is:
May not sit still in pre-flight briefings. Hopefully does not get out of seat in flight!
Funny, hey?
Yep, ‘funny’ as in ‘really strange’.
The form requires the instructor to express a view on whether the student’s behaviour is “normal” or not. I wonder where the instructor’s opinion rates in the NHMRC’s hierarchy of evidence. I do
not wonder about what CASA Avmed does with any evidence detrimental to the student pilot’s interests.
I do hope the student – or their legal guardian in the case of a minor - is informed that the assessment is being made by the instructor and will be submitted to Avmed. And I wonder what protections an instructor has for the consequences of the opinions he or she expresses in the form.
The creators of this form are evidently completely divorced from a thing called “reality”. If a student pilot manifests the kinds of behaviours listed in the form, the student pilot is unlikely to pass the theory and practical exams that have to be passed in order to obtain a pilot’s licence.
CASA Avmed must be labouring under the misconception that before it invented the form and turned instructors into informants on student pilots, it was possible for a person with some of these kinds of symptoms to pass the theory and practical tests necessary to become a pilot:
- often fail to give close attention to details or make mistakes in theory lessons, pre-flight preparation or in-flight instruction
- often have difficulty sustaining attention in theory lessons or in-fight instruction
- do not seem to listen when spoken to directly
- do not seem to listen when asked questions in theory lessons or in-flight instruction
- do not follow through on instructions given in-flight
- have difficulty completing lessons
- do not pay attention to or follow through or complete checklists appropriately
- have difficulty organizing tasks and activities
- have difficulty prioritising tasks e.g. during pre-flight preparation
- inappropriately organise cockpit tasks e.g. aviate, navigate, communicate
- often avoid, dislike, or are reluctant to engage in tasks that require sustained mental effort
- have difficulty with studying theoretical aspects of learning to fly
- do not sustain attention to in-flight tasks
- cut in on other aircraft or be inpatient waiting for take-off
[The author of the form meant “impatient” but may have been distracted by other stimuli rather than concentrating on proof-reading the form. Further, the author of the form evidently hasn’t spent much time sitting in a stiflingly hot cockpit at a runway holding point, having called ‘ready’, watching a dot in the distance taking a couple of minutes to arrive at the threshold of the runway, triggering a further delay due to wake turbulence risk, while the instructor – in loud and ‘colourful’ language - speculates on the air traffic controller’s parentage and IQ.]
- have difficulty conforming to safe separation in circuit pattern
- have difficulty holding sustained attitudes/altitudes
- lose things necessary for tasks or activities
- misplace or leave behind headsets, slide rules, maps, flight plans
- forget to replace fuel caps, pitot tubes etc
[Plenty of pilots have forgotten to replace fuel caps, including me once. But I’ve never replaced a pitot tube - I’m not qualified to. Maybe pitot tube replacement is now part of the pilot syllabus?]
- have difficulty maintaining constant headings, altitudes etc because of distraction e.g. looking at things on the ground
- miss items on checklist, pre-flight checks
Does CASA Avmed
seriously believe that, but for its beneficent intervention, the skies would be filling up with pilots with manifold behaviours from that list? Seriously?
I get it that ADHD and ASD are ‘conditions’ that have consequences in principle. That doesn’t turn those conditions into something to be micro-managed by CASA Avmed.
It’s like CASA Avmed’s bright idea that we now have to pass the eye test in the DAME’s clinic with two different pairs of eye correction, as if that ‘proves’ compliance with CASR 67.200. I don’t ‘front’ my DAME with
either of the pairs of glasses I wear or have available while flying. Taking those pairs of glasses to the DAME’s clinic would be stupid. I need and keep those glasses in my aircraft, which isn’t parked in the DAME’s clinic.
(Purely coincidentally, I was sitting in a doctor’s clinic very recently, waiting for an ultrasound on my baby - not my real condition; I’m actually completely blind, but don’t tell CASA). The TV in the corner of the waiting room started playing an item about ADHD. I found it very informative. At the end there was disclosure of the common side-effects of the drugs usually given to children to ‘treat’ ADHD: Lack of appetite and difficulty in getting to sleep. I thought:
Those are the drugs we need to fill kiddies with. What could possibly go wrong?)
People with fragile egos and a commitment to a noble cause sometimes struggle with being ordinary and accountable
Whether someone joins CASA as a doctor or lawyer (or butcher or baker or candlestick maker), the person is the subject of many statutory obligations and constraints on their activities. Those requirements and constraints cannot be complied with unless they are understood and accepted. Administrative law is actually about protecting people from the likes of CASA and the kinds of decisions that CASA Avmed is in the habit of making with increasing and unnecessary frequency. That’s why the AAT dealt with one of Dr Manderson’s predecessors in the way it did as I’ve quoted earlier.
My first hand observation is that doctors as bureaucrats often struggle with the concept of having to comply with legal requirements and constraints imposed on their decision-making. They don’t like their opinions being challenged. They don’t like being told that they are just ordinary bureaucrats making ordinary administrative decisions that are the subject of laws that have been around for decades. But they are, whether they like it or not.
The gap between the rhetoric and the practice
I welcomed the panel discussion about "evidence-based medicine" but thought: "If only...".
I noted the reference to the "global body of literature" and "consensus" but thought: "If only...".
And then there was the NHMRC hierarchy of evidence. That's the hierarchy CASA Avmed usually quotes just before proceeding to 'cherry pick' whatever 'evidence' it can find to put a person's medical ‘condition’ into the worst light and spinning that into a potential aviation catastrophe. The subjective opinion of someone in Avmed is magically elevated in the hierarchy. The consequent ‘risks’ demand the most intrusive, restrictive, costly and – in some cases – life-threatening impositions on pilots that Avmed can identify.
My most recent foray in the AAT arose out of a CASA Avmed decision the reasons for which were sprinkled with a bunch of high-sounding rhetoric and an evidence pyramid but were in substance based on ‘cherry picked’ studies and the Avmed doctor’s non-expert, strongly-held opinion. Australia’s foremost expert in the area in question described the decision as being based on “pseudoscience”. That’s why CASA backed down before a potentially embarrassing Tribunal decision.
My lawyer in the matter told me that the practical standard in CASA Avmed matters is this: “They’ll do whatever they like and will only back down if there’s a risk of them being embarrassed.” That’s the extent to which the integrity of the Avmed function has been compromised.
The discussion about “evidence-based medicine” led me to wonder…
Is the ‘non-CASA’ medical fraternity systemically incompetent?
A thing that perplexes me about CASA Avmed’s approach over the last decade or so is the implication that ‘non-CASA’ doctors and specialists are
not practising evidence-based medicine,
not reviewing the global body of literature to find out whether there is consensus and
not aware of and applying the NHMRC hierarchy of evidence. Why else would CASA Avmed so frequently second-guess or dismiss the opinions of the ‘non-CASA’ medical fraternity these days? Perhaps CASA Avmed is ‘saving’ us from that fraternity’s systemic incompetence? Perhaps CASA is doing us pilots a favour?
I don’t understand why I can’t identify any medical professional independent of CASA who’ll say: “CASA Avmed is nailing it. We’ve so much to learn from CASA Avmed.” The statements they make are invariably to the opposite effect.
Even more perplexing is how someone from the ‘non-CASA’ medical fraternity becomes ‘more competent’ and ‘more expert’ than he or she would otherwise be, merely as a consequence of becoming a member of CASA staff. I’m guessing there’s some form of transmogrification, perhaps involving Kool Aide. Who’d know. All I can do is respectfully urge Dr Manderson not to attend any strange rituals or consume any bubbling potions proffered during the CASA induction process.
Conversely, I can’t work out how 20 more years of aeronautical experience and legal practise after bailing out of CASA makes me less qualified than I was, back then, to spot specious nonsense cloaked in aviation safety rhetoric.
But I digress …