View Single Post
Old 21st Sep 2015, 21:02
  #248 (permalink)  
Lead Balloon
 
Join Date: Nov 2001
Location: Australia/India
Posts: 2,777
Gather 'round, ppruners ....

Once upon a time, in a far away land, there was a pilot named Jominic Dames.

Like most commercial pilots, Jominic worked in an environment that meant he was almost always in a double bind: He was expected to comply with his employer's operations manual (most of whose content was dictated by the regulator) and the aircraft flight manual, plus all the rules including rules about fatigue and fuel management and diversions. But, alas, all of those documents contained mistakes and the rules were ambiguous.

One dark and stormy night, Jominic took off while tired, in an aircraft whose fuel capacity and performance were not suited to the mission at the altitude he was forced to fly. He didn't notice that In the seat beside him there was a mannequin rather than a co-pilot.

Along the way, he was given erroneous weather information, and some relevant weather information was not provided. This meant he was misled about the weather conditions and trends at his destination. He then made the mistake of pressing on to his destination, and had to ditch in the ocean when a safe landing at the destination was not assured. All POB survived and were recovered, but some suffered lifelong physical and other injuries.

It was, of course, all Jominic's fault. There were no systemic issues. The performance of the life vests was Jominic's fault. The procedure for preparing the raft for ditching was Jominic's fault. The erroneous and withheld weather information was Jominic's fault. The unsuitability of the aircraft allocated by the operator for the mission was, of course, also Jominic's fault.

The regulator and transport safety investigator reached the obvious conclusion, and launched an investigation to prove it, accordingly.

Fortunately, the regulator and transport safety investigator were not distracted by irrelevant issues like the commercial and political connections of the operator which employed Jominic, the content of reports of audits of the operator carried out by the regulator before the accident, or the circumstances in which flight information services had been withdrawn by Airservices from the Australian territory that was Jominic's destination. Nor were the regulator or transport safety investigator diverted to trivialities like the content of the CVR or a proper analysis of the actual fuel capacity and performance of the aircraft in question. An earlier transport safety investigator report about the unreliability of weather forecasts at the destination was irrelevant. The 50/50 split between FOIs on the question whether Jominic was obliged to divert was neither here nor there. A competent pilot would, of course, have known the correct answer: yes and no. A competent pilot would have known that there were errors in the weather information provided by flight service, and that relevant weather information had been withheld.

In accordance with contemporary accident investigation techniques, just culture and the systems approach to identification of the causes of errors, Jominic was proved to be the cause of the accident.

In a happy coincidence, the matter could be dealt with 'flexibly' by the regulator.

Accordingly, the operator was given the flexibility to continue operations as if nothing had ever happened, and everyone else came to the same conclusions about themselves: FIGJAM.

Except, alas, for Jominic. He received a different kind of 'flexibility' because he had embarrassed all of the wrong people. Such was his level of incompetence that the regulator considered that gathering the evidence to support a prosecution would not be in the interests of air safety. The appropriate regulatory response to such a heinous safety risk was to f*ck Jominic over administratively, indefinitely.

And to this day, Jominic appreciates the benefits of the regulator having "flexibility".

Of course, it's all just a fairy tale and could never happen in the real world.
Lead Balloon is offline