LL - The first time that style of diagram appeared was in the QF1 report. It is an attempt to put the Reason model in a box and as you have highlighted it may be theoretically impressive but doesn't give a real time indication of what contributes to an accident. Like a lot of HF specialists from a cognitive psychology background they lack the practical knowledge of what happens in a flight deck.
Absolutely spot on Lefty and I believe you will find that the Doc was also responsible for the QF1 causal chain diagram (
Boeing 747-438, VH-OJH Bangkok,Thailand)...
However let us go back to the PelAir debacle and take the top two headings of the Doc's causal chain diagram - for the Lockhart disaster - to point out why it is simply unacceptable for the re-investigation to be conducted by the ATsB i.e. 'bureau judging bureau'...
From
3.5 Report preparation (November 2010 to March 2012) of TSBC report:
At this time, the IIC prepared and sent to CASA briefing sheets outlining two safety issues raised in the draft report: 1) fuel-management practices for long flights, and 2) Pel-Air crew training and oversight of flight planning for abnormal operations.
In preparation for a follow-up meeting with CASA, the draft report and supporting analysis were reviewed by an acting team leader who raised concerns to the GM about the adequacy of the data and analysis used to support the draft safety issues.
In response, the GM directed a third peer review by two operations (pilot) investigators who had not previously been involved in the investigation.
They completed it on 11 August 2011, and provided six pages of comments, suggesting that the organizational issues identified in CASA's investigation report were significant and needed to be developed further in the ATSB report. The IIC reviewed the comments and provided a response to the GM on 05 September 2011.
But remember that by then the IIC had essentially distanced himself from any aspect or association with the CAsA parallel investigation and that as consequence Terry & co - in the interest of the 'spirit & intent of the 2010 MoU - saw no need to release CAIR09/3 till mid 2011...
However it is now worth revisiting what these two impartial pilot investigators straight away saw when they finally got to see the infamous CAIR09/3 (IMO it stood out like dogs balls):
1.17 Organisational and management information
The flight was conducted by Pel-Air Aviation Pty Limited. At the time of the accident PelAir held Air Operator Certificate number 1-1VAV2-03. This was issued on the 05 June 2009 and was valid to 30 June 2012. The AOC authorised the holder to conduct Regular Public Transport, Charter and Aerial Work operations. The Company was headed by the CEO as Director and nominated senior person. The company employed a chief pilot and a number of pilots. The company is overseen by the Bankstown office as part of CASA Operations and was last audited by the Bankstown office staff during February 2009.
Following the accident the Bankstown office conducted a special audit of the Pei-Air Air Operator Certificate coincident with the aircraft accident investigation and a number of issues relevant to the accident were identified. These are as follows:-
1.17 .1 Fuel Policy and Practice
Inadequate fuel policy for Westwind operations.
Pilots use their own planning tools and there is no control exercised by Pel-Air Aviation Pty Limited to ensure the fuel figures entered are valid.
No policy exists to ensure that flight and fuel planning is cross-checked to detect errors.
No alternate requirements specified for remote area and Remote Island operations.
The Operations Manual specifies 30 minute fuel checks- this appears to be largely ignored by operating crew.
Criteria to obtain weather updates not specified in Operations Manual.
Practice of obtaining weather varies among pilots and does not appear to be conducted at appropriate times to support decision making.
No consideration of loss of pressurisation and an engine failure.
1.17 .2 Operational Control
No operational decision-making tools provided to support crew in balancing aviation versus medical risks.
Once !asked, the pilots operate autonomously and make all decisions on behalf of the AOC. The AOC exercises little, if any, control over the operation once a task commences.
The company does not provide domestic charts or publications to pilots and does not ensure that the pilots maintain a complete and current set.
In many cases inadequate flight preparation time is provided. (Normally pilots are notified two hours prior to departure regardless of when the company becomes aware of the task).e Failure to maintain required flight records ·and no apparent checking by the company.
Pilots use their own planning tools and there is no control exercised by Pei-Air Aviation Ply Limited to ensure the data entered is valid.
1.17.3 Training
Inadequate CAO 20.11 training (life raft refresher and emergency exit training deficient).
Inadequate documentation of training programs.
No formal training for international operations.
Inadequate training records for pilot endorsement and progression.
Inadequate records of remedial training.
Endorsement training is the minimum required (five hours) and relies on regular operations to consolidate training.
No mentoring program for First Officer to Command.
Deficiencies in training records identified.
1.17 .4 Fatigue Management
Over-reliance on FAID as the primary fatigue decision making tool.
Inadequate adherence to FRMS policy and procedures.
Excessive periods of 24/7 stand by.
Lack of FRMS policy regarding fatigue management for multiple time zone changes.
Fatigue hazard identification, risk analysis, risk controls and mitigation strategies not up- to-date and documented. (Advice provided during the FRMS review indicates that Pel-Air Aviation Ply Limited considers the ad hoc aero-medical operations to be its highest fatigue risk and yet there is no recent documented evidence to confirm these risks are being actively managed).
1.17 .5 Drug and Alcohol Management
Failure to ensure that drug and alcohol testing is conducted after an accident or serious incident.
These issues have resulted in requests for corrective action being directed to the company and management plans to address, these have been implemented.
Although obviously a basic summary of the organisational/management influences; when read as a whole it does paint a very disturbing picture...
Is it any wonder that Terry & co a) withheld CAIR09/3 from the IIC as long as possible; and b) tried to hide the document from the Senators within the body of - Attachment 5
(PDF 6032KB)...
The observations of the pilot investigators also brings into sharp context this email from quite obviously a very Senior Transport Safety Investigator..
18Internal ATSB email regarding the inconsistency in safety knowledge of ATSB staff (dated 6 August 2012), received 10 October 2012;(PDF 1597KB)
Many of my arguments that have been rejected have been ones where I have applied safety management methods and tools, and those arguments have been rejected by a reviewer who looks from a regulatory viewpoint instead of a safety management viewpoint. Yes, regulatory arguments are the easiest to defend, but the maintenance of high reliability, complex systems must rely on so much more than only regulatory compliance. To make useful comment on these matters relies on our belief in, and use of, contemporary safety management theories and methods. To me, this was particularly evident when CASA's Norfolk island audit report came into our hands, and some of the arguments I had tried unsuccessfully to include in the report were subsequently included on the basis of CASA's findings, not mine! When I have to rely on CASA's opinion to persuade the ATSB, how can I claim that the ATSB is independent when it investigates CASA?
How indeed??
I'll be back...
