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Old 29th Nov 2017, 22:08
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Sunfish
 
Join Date: Aug 2004
Location: Melbourne, Australia
Posts: 7,609
A "Forgetting" Organisation?

One of the articles of faith I absorbed as a teenager and young adult was that aviation institutions in Australia were "learning organisations" because the cause of aviation safety demanded nothing less than complete transparency by everyone engaged in the industry. How wrong I was.

I don't know how I received this idea. It might have been from reading volumes of the old crash comics in the Ansett library. It might have been reading the volumes of internal incident reports and investigations into component failures and fixes. I later wrote a few myself that I like to think embodied that spirit; transparency, no blame or encomium, just learning so it didn't happen again.

I missed the giveaways that I was wrong in ab-initio flight training. The strange silences when I asked about specific things. Being cautioned against writing things up in the MR. The "it always does that" response to aircraft behaviour queries. A near miss learning STOL at YCEM - a real "gotcha" that could have killed us, but nothing heard thereafter. The fire caused by a rag in a heater duct. Then of course bending a Cessna firewall from a behaviour by myself that must have been as old as aviation itself but that was new to me. Some learning. Others are going to repeat these mistakes.

I thought that at least the ATSB was a learning organisation what with its unbiased safety reporting and all. But after the initial Norfolk Island report I discovered that all it was interested in doing was being a political fig leaf for its masters. CASA, from reading PPRuNe, turns out to be simply a punitive regulator with no interest in learning, merely rigid compliance. For example where is the scholarly work on fuel planning, including traps for young players? All there is is a regulation; don't run out of fuel - 50 penalty points and a criminal record. You cant learn in the CASA system because learning involves testing new ideas, and that is illegal and punished. You can't learn from the errors of others if people are too scared to admit a mistake. "Outcome based" training is another fig leaf to hide a lack of learning and understanding.

I now look at what I have built and think of the numerous "non compliances" a CASA Airworthiness inspector could find if they really tried. Shall I risk finishing it and flying it? I'm sure it will fly but its the regulator I fear. I think of the people whose careers imploded because CASA did not like their "attitude" or who became victims of forensic searches for errors in records looking for something to convict. I read in the AAT decisions about serial injustice.

I read about the minutiae of maintenance regulations, the behaviour of the CASA medical section. Is it any wonder that most pilots have at least two doctors? I think of the "maintenance statement" i have to write in the aircraft logbook and how it might one day be used to convict me of crime. I decide that the best way is to write as little as possible. Not the safest way, the best way from a legal standpoint. I vow never, ever, to fly anywhere near a CASA operative. I make a mental note to make myself scarce if I ever detect one. These people are not teachers of anything except abject obedience.

The characteristics of a learning organisation:

An atmosphere of trust and acceptance

People taking ownership of their learning

Senior managers and leaders walking the learning talk

Values and vision that people robustly debate, share and articulate

Rich communication and feedback loops

Collaboration between different silos and with external partners

Staff excited about their work and about belonging to the company

Learning evident at individual, team and organisational levels

Systems in place to support learning

Last edited by Sunfish; 30th Nov 2017 at 01:19.
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