PPRuNe Forums - View Single Post - Two helicopters collide - Gold Coast, Queensland - Sea World 2/1/2023
Old 15th Jan 2023, 23:32
  #400 (permalink)  
Lookleft
 
Join Date: Jul 2008
Location: Australia
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Good points SASless. James Reason was initially looking at the oil and nuclear industries and why such regulated and SOP dependent industries still had catastrophic accidents. Aviation is very similar. The Swiss cheese model does indeed work the other way and the ATSB were early adopters of investigating from the accident back up through the layers. Equally, if you can start at the accident and work back then the organisation can put in place structures that look at how it goes about its business and look for the "holes". The jargon is risk analysis, safety management systems and safety audits. In theory that should be good enough to trap and close the holes in the cheese but it depends on how serious an organisation is in paying attention to the information that it provides. Regulators will look at the manuals and tick the box that they are in place. CEOs will sign their name to a safety statement but then allow commercial consideration to override any safety consideration.

As an example, a former Jetstar CEO stated that operations into Ballina kept him awake at night. Jetstar had a near miss where one of its jets came within 300' of hitting a light aircraft yet they still operate into Ballina with the airspace not that much different to when the near miss occurred. Why didn't the CEO simply stop all flights into Ballina until a control tower was put in and Jetstar cover some or all the cost? If (or when) there is a collision it won't be bad luck, it will have been inevitable.

It requires commitment from all levels of an organisation big or small, that safety is the prime consideration when changes are made to the way business as usual is done. The statement "Safety is no accident" is both cliche but true. When things are going well then the system is apparently working. By well I also mean that accidents are not happening. In this accident there must have been something different in the way things were usually done.

This was a clear day with two experienced pilots in modern machines. If this can happen to an organisation ,on the surface well run and well managed and considered as just plain bad luck, then the only way to avoid such things in the future is to stop all scenic flights out of Sea World. If Reason's model has any credibility, which after 25 years has not proved to be flawed, then there are issues that only a thorough investigation of the whole organisation can uncover.

As far as your statement: "How does an Aviation Safety Advisor sell the "Reason" method to Senior Management?" is concerned, that is the million dollar question. It would only be after a fatal accident such as this that it becomes a bit easier.
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