Skymaster - Airtex & Canley Vale Rd Crash

[MaxTOW]

Firstly - very considered condolances to those who are close to Andrew Wilson & nurse/passenger Kathy Sheppard in regards to the crash at Canley Vale Rd.

I'm raising this new thread because I'm wanting to question the responsibility & culture of the owner, or controlling people of the organisation, that has lead to this accident occuring.

How often can company culture drift down from an owner to employees? Its a well known fact of business organisation that seemingly small, intricate decisions can have much larger effects than expected, on people subordinate in an organisation.

I want to make it clear I'm not trying to imply any blame here - either about the pilot (Andrew Wilson), or other people working in the organisation (LAME workshop employees), or trying to start any pre-diagnosed self run crash investigation - leave that people & organisations with greater resources. My aim here is to get what peoples thoughts are on Airtex and subsequently Skymaster. I personally have known several people owning/running Airtex, and the ethical side is questionable; remember AAA airlines? :mad:

We all know that a long time ago, CASA started to review AOC holders on basis of the culture in their organisations, with both support and evalution / assessment of the entire organisation (maintenance - pilots etc), top down. Its pretty hard to change culture - it can be so driven by a small number of people, attitude (very hard to change) & money.

We all love to hate CASA. But what of this accident? Would have a greater look at their own (AOC holder / owner at top) culture; possibly just one person, have saved these peoples lives? Or is CASA more responsible, being right at the top of the food chain? There's a can of worms. :eek:

[Tidbinbilla]

I will leave this thread up - for the time being. Be VERY careful what you write in response, people. Think "legal".....:E

TID

[tipsy2]

IAW Tiddles wishes........I will speak generically.

MaxTOW is I believe talking about Safety Management.

SMS is often denigrated (read missunderstood) by small organisations as being too expensive, too complicated and too difficult and only for big organisations.

SMS does not have to be any of those negatives, infact it can be quite as simple as a one page statement. And yes it can also be a suite of manuals and many staff but the desired outcome is still the same.

Organisational culture is the sum of the inputs of everybody in an organisation, yes it must be believed in and fully supported from the top. We minions must report and pursue from the bottom up and drive the system.

SMS does work, but it is us that will drive the very necessary continued improvement in the system that in the longer term is to our benefit as individuals.

The benefits to an organisation are too many to detail here, suffice to say having an accident can and has destroyed organisations in the past.

OK Tiddles!!!!

Tipsy

[MaxTOW]

Tipsy2 - Yes, that was exactly what I was talking about (you explained very clearly). What you say puts my comment in a lot better perspective. It is onerus on everyone in an organisation. No desire to denigrade here.

[remoak]

Is there a resistance to declaring a MAYDAY or PAN-PAN

I think there is, but not for the reasons suggested. I think it is more a product of human nature, especially amongst young, confident (but inexperienced) pilots, to under-state emergencies, in the belief that they have it under control and they can find a way to get down safely. Many would see it is a good thing to be able to tell the story in the bar afterward about how close they came, while at the same time doing it all by themselves with no outside help.

In this case, it seems the pilot thought he had it well covered, but things started to unravel as he got lower (as they often do), and he found himself rapidly running out of options. He probably thought the road was a viable last option, but just misjudged the obstacles.

Listening to the Centre tape, it is clear that the controller wasn't hanging around and was making preparations whether the pilot asked for them or not. Good for him.

So I think that this accident had less to do with company culture and more to do with a "can do" attitude that many young pilots have.

I would see a poor company culture typified by pressure to take aircraft that weren't properly equipped, or fly VFR rather than IFR in order to save money, in other words things that involved a conscious decision before the aircraft left the ground.

But then I don't know the company, so...

[VH-XXX]

Have been there, done that, not commercially, but for me to call a mayday the wing would have to be falling off or in a S/E I'd be calling it only if I knew that the outcome was going to be bad and I was going to crash and not be able to tell my story later. If I was out in the open and thought that there was a good chance of survival, depending on how long I've got left to prepare for the landing I probably might not bother.

[hihosland]

Is there a culture/philosophy problem associated with twin engined light aircraft?

Does the promotion and training associated with light twins instill a mindset that couples one engine out purely with the start of the challenges of asymetric flight?

Would it be better if one engine out was also more firmly considered as the first symtom of impending total power failure?

[Jabawocky]

Yes....there is. Piston twins despite their marginal paper performance vary quite a bit, so basically assum you have marginal help at best.


J:ok:

[Howard Hughes]

We minions must report and pursue from the bottom up and drive the system.

I would argue that the system needs to be driven from both directions. If those at the top fail to take action on the information that is put forward, those submitting the imformation soon get disinterested and stop inputting to the system.

[Sunfish]

Once you declare Mayday or Pan, the paperwork starts, assuming of course you survive.

[mmhbtower]

Sunfish

and there will be no paper work after you have an incident or accident!

it matters not if you say the words it just gets you help faster, why is there such a reluctancy to declare?

[ForkTailedDrKiller]

Once you declare Mayday or Pan, the paperwork starts, assuming of course you survive.


My experience does not support that statement. Maybe it depends on how much damage is ultimately done and whether or not anyone is injured or killed.

In my case(s) - A statement was given to police. An incident report was submitted to CASA/ATSB.

Nothing more heard!

Dr :8

[Horatio Leafblower]

Once you declare Mayday or Pan, the paperwork starts

Without referring to the case in point, I make the following observations from my own GA career:

Re: the quote above: I cannot think of a less legitimate reason to not comply with what is a perfectly clear recommendation in the AIP. It is this sort of attitude which pervades GA - supposedly "wise" old heads declaring that they don't comply with rule X, Y or Z because they're smarter than that :ugh:

These rules are written in blood, yet we allow ourselves to dodge and weave and pretend that the rules don't apply to us for some "reason" that seems legit at the time.

As Commercial Pilots and ATPL holders we MUST start holding ourselves to a higher standard. For a bit of inspirational reading I refer you to Tony Kern's Blog (http://commandersintent.convergentperformance.com/2009/11/aviation-professionalism-why-we-cant-go.html).

When I was a young buck my head was filled with bar stories and "received wisdom" which, in that environment, led to a few colourful (career limiting) incidents :ooh:

I received a few "attitude adjustments" and my attitude to safety & compliance today is somewhat different. With a bit of maturity (and more than a couple of scares) I started examining my actions and beliefs. Today, the decisions are simple: "What does the book say? Do that."

The guys imparting their wisdom at the Aero Club bar haven't faired so well.

The bloke who (truthfully) bragged that he had "barrel-rolled every aircraft I've ever flown" is dead.

The bloke who (truthfully) bragged that he always got in (but complained, falsely, that the operator forced him to break the rules) flew a Metro into a hill, and is dead.

The bloke who (incorrectly, as it turns out) reckoned he didn't need Aerobatic training is dead.

The bloke who reckoned Ops manuals are all bull**** and that CASA is only interested in "paper safety" lost his AOC and his airline.

Bizzarrely, the professional pilot who always reminded me to never press the weather himself flew VFR into IMC at low level :rolleyes: - and he's dead, too.

Culturally we seem to tacitly accept the idea that "It's GA, therefore the rules are optional". It seems to me that many of us seem to forget that "Professional discipline" can apply to any level of operation - from RAAus to the Space Shuttle. But we must choose to apply it.

The pilot is simply the last line of defence in the system - and in these days of automation that's the only reason we're on board. As the mechanical and other faults become more and more rare, and as "Pilot Error" and other human cultural factors come more and more to the fore, how long before "they" consider eliminating the greatest hazard on commercial aircraft - the pilot? :confused:

[Aerozepplin]

Once you declare Mayday or Pan, the paperwork starts, assuming of course you survive.

What a strange statement. Its the nature of the failure or defect, the outcome, the danger, and specifics of the situation that decides what happens with an occurrence, not the phrase the pilot issues on the radio. A mayday or pan pan call is a tool to help those involved resolve a situation.

I'd say there would be more hassle for you if it was found you should have declared urgency or an emergency and didn't.

[HarleyD]

Horatio Leafblower, Speaking Generally about GA - Well said that man!

And we may aslo look to the fact that many young aspiring pilots would have been in complete agreement if they had lived to tell the tale and moved on in their career to a similar stage os your own, without letting all those aeroclub bar stories and peer associations be the ongoing basis for evaluating their own capabilities and influencing decision making at critical moments.


The trick seems to be to bypass the individual learning process and accept that there a real rules there that, as was said, 'have been written in blood'

Tragic though this particular event has been, i think that the discussions have been a means of bringing many issues to the fore without the usual D&G whining and moaning, rather serious inrtospection into an industry that from the boggy pilot to the outback operation owner/operator we all have a stake in this and it is in everyones (including the flight nurses and the fare paying punters) interest to look at the aspects of business, engineering, operational and safety cultures that can contribute to such accidents and assist the holes to line up un the swiss cheese.

There are lessons to actually be learned here, and it will take some effort to do something about it and not just slowly slide back into the 'tribal' culture that is the GA environment.

We need cultural change in GA, for everyone, not just operators and we can stop blaming the regulator, CASA has an important role and it needs to show some serious leadership and earn the respect that is neccessary for this process to be of significant benefit to an industry where the next dollar is king. Businesses should be profitable and flourish because they are safe and serious about it, not suffer for it.

The insurance companies will be bigger players in cultural shift as well, they are already showing initiative with safety programs and certification standards and will continue to play and increasingly important part, but if you don't want them to run the industry then we all need to play abit more of the professional pilot (not just commercial pilot) CPL means you can fly for you living but prosfessionalism is an attitude that is up to the individual in GA.

[MaxTOW]

Horatio, Tipsy2, Owen Stanley, Remoak. Like your inputs here (not that everyone else's isn't good). "As Commercial Pilots and ATPL holders we MUST start holding ourselves to a higher standard.",ditto. I guess that one comment sums it up. "Driven from both directions" (Howard) - agreed also; we need to consider that our well driven actions can have benefit for all. Owen Stanley, those comments are very appliceable too; Percieved pressure for OCTA and non-declaration of phases. I guess my reason for starting this thread was to prod us into considering what can lead to an end affect from such a seemingly small starting point. Definitely not a go at one organisation - all are up for being questioned.

[snoop doggy dog]

My condolences to the family's of the 2 that lost their lives.

There is a lot to be said and gained by have the right "culture" within a company.

A good Culture in a company starts from the top down, with the one's up the top embracing and establishing good systems and procedures. Open communication, proper SOPs, good feedback to staff and top management adding value to all this by beleiving that safety is the primary task. Not money!

The Power Distance (PD) relationships of some company's is very questionable. There have been operators in very recent times coming to greif with PD issues that more than likely helped the holes in the swiss cheese line-up.

Good CRM pays dividends for the company's that take it seriously. CRM is more than a "tick the box" exercise for CASA, however in Australia it seems to be the way company's generally perceive the exercise, and it "costs" money!

There is much more than can be written here.

It is a shame when accidents happen and lives are lost.

1. Safety
2. Passenger Comfort
3. Schedule
4. Profits

Many get the order of priority wrong when making decisions.