Merged: Senate Inquiry
GAFA
Stuart Haynes is the Manager Flight Training and Checking not the chief pilot.
Stuart Aggs is the GM Safety Systems
Rick Howell is the GM Flight Operations and is the Head of Flying Operations, the Chief Pilot in the old vernacular.
Stuart Haynes is the Manager Flight Training and Checking not the chief pilot.
Stuart Aggs is the GM Safety Systems
Rick Howell is the GM Flight Operations and is the Head of Flying Operations, the Chief Pilot in the old vernacular.
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John McCormick of CASA said
Which part?
Or is it the way that CASA only check one franchise and all the other franchises are checked and self-regulated by QF Group to see if the 'brand reputation' is being maintained?
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The Kelpie
McCormick also said there was a new audit of Jetstar schduled for May this year,
Or is it the way that CASA only check one franchise and all the other franchises are checked and self-regulated by QF Group to see if the 'brand reputation' is being maintained?
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The Kelpie
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Who learnt to drive in a Kenworth truck? Ask any passenger if they would prefer a newly qualified pilot with little experience flying them in a multi million dollar jet?
Time for a reality check here....
Yes you can train someone to fly a jet with only 200 hours experience, you could teach a monkey to do it. But what happens when it's not a fine and beaut CAVOK day and all systems aren't working as they should be? Oh yes you can pass the sim check, but what about when it happens FOR REAL? Cant hurt yourself or anyone else in a sim. You draw on from past experience, prioritise and apply what you have learnt. Hard to do if you have no experience. You need to remain calm, fly the aeroplane and sort the problem. You need the spare head space to focus on the issue at hand, not just thinking about how to fly the plane. Situational awareness? And it's not just all up to the Captains to deal with it. They need to delegate tasks, but as an FO you also need to be able to prioritise tasks being handed to you and provide valuable support. Hence the reason there are two pilots up front.
It's not about a 'right of passage', it's a point in your career when you're suitable for the job. Who passed uni and became a top manager?
At 500 hours you think you know it all. At 1000 you realise you don't know that much. Every thousand after that you become more humble. Applied knowledge through experience.
It also needs to be the right hours in the right aeroplanes. 1500 hours in a C172 doesnt give you sufficient background for a jet.
As for the airforce and pilots flying jets with minimal hours. They are the cream of the crop. Take a look at their selection process. And they are trainined by the best of the best to impeccable standard.
In my opinion, if you want to fly for the airlines, learn to fly and gain the required experience. Enjoy the journey, it's a fantastic career path with many life experiences. If you started off in a jet, what do you have to aspire to? And people wonder why there are issues with Gen Y.
Time for a reality check here....
Yes you can train someone to fly a jet with only 200 hours experience, you could teach a monkey to do it. But what happens when it's not a fine and beaut CAVOK day and all systems aren't working as they should be? Oh yes you can pass the sim check, but what about when it happens FOR REAL? Cant hurt yourself or anyone else in a sim. You draw on from past experience, prioritise and apply what you have learnt. Hard to do if you have no experience. You need to remain calm, fly the aeroplane and sort the problem. You need the spare head space to focus on the issue at hand, not just thinking about how to fly the plane. Situational awareness? And it's not just all up to the Captains to deal with it. They need to delegate tasks, but as an FO you also need to be able to prioritise tasks being handed to you and provide valuable support. Hence the reason there are two pilots up front.
It's not about a 'right of passage', it's a point in your career when you're suitable for the job. Who passed uni and became a top manager?
At 500 hours you think you know it all. At 1000 you realise you don't know that much. Every thousand after that you become more humble. Applied knowledge through experience.
It also needs to be the right hours in the right aeroplanes. 1500 hours in a C172 doesnt give you sufficient background for a jet.
As for the airforce and pilots flying jets with minimal hours. They are the cream of the crop. Take a look at their selection process. And they are trainined by the best of the best to impeccable standard.
In my opinion, if you want to fly for the airlines, learn to fly and gain the required experience. Enjoy the journey, it's a fantastic career path with many life experiences. If you started off in a jet, what do you have to aspire to? And people wonder why there are issues with Gen Y.
I want to tell YPGV something about "experience".
I am a low time private pilot. I will never fly big jet aircraft.
However, I believe that if you can safely operate a little aircraft then you are going to be able to safely operate a large one, furthermore you will do it better and more safely than someone with no GA experience. The reverse is not true, as numerous instructors who have sat beside airline captains in small Cessnas will tell you.
There is such a thing as "seat of the pants" experience acquired in GA and small aircraft that is priceless. It is an innate understanding of the forces acting on the aircraft at all times, I say "innate" because you ****ing feel them directly.and sometimes violently, and learn to take immediate corrective action - or else.
You do not get this feeling in Three hundred tonnes of aircraft, however exactly the same forces are at work, as can be seen in the many videos of crosswind landings of large jets. What the basic GA flying does in my opinion is give a pilot a basic feeling of anticipation of what the aircraft is about to try and do much faster than someone with no GA experience, and therefore allow them to react faster to stimuli.
I base this opinion on my knowledge of the behaviours of sailing boats - vessels that move in Two different fluid streams at once - wind and water, that are in many ways considerably harder to manoeuvre than aircraft, and the people that helm them.
I learned to sail at age 9. I have sailed more or less continuously for fifty years. I can say categorically that those that learned to sail in a little boat can sail a big one competently after instruction, much more competently than someone with no small boat experience.
It is very common in sailing to see a person come late to the art with no small boat experience, buy a very large, heavy and expensive vessel, acquire experienced crew, and instruction, then attempt to race it.
No matter how intelligent they are, no matter how much instruction is given, no matter how much money they throw at the boat (Five million is typical, and a million a year in expenses) it always ends in tears, because even the best of them is ALWAYS half a second or more behind the boat compared to an experienced dinghy sailor.
And Jetstar had a heavy landing? Surely that is getting behind the aircraft? Surely a botched approach is the same thing - getting behind the aircraft.
Of course there are "bad habits" in GA and operational skills that can be taught and learned, like the care and feeding of engines, navigation, etc., but the fact remains, how do you ensure that pilots don't get behind the aircraft? I don't think you can teach that in a large aircraft.
My gut feel is that the cadets schemes and "GA is not relevant" crowd are self serving arguments by those who want to drive costs down, and nothing else.
I am a low time private pilot. I will never fly big jet aircraft.
However, I believe that if you can safely operate a little aircraft then you are going to be able to safely operate a large one, furthermore you will do it better and more safely than someone with no GA experience. The reverse is not true, as numerous instructors who have sat beside airline captains in small Cessnas will tell you.
There is such a thing as "seat of the pants" experience acquired in GA and small aircraft that is priceless. It is an innate understanding of the forces acting on the aircraft at all times, I say "innate" because you ****ing feel them directly.and sometimes violently, and learn to take immediate corrective action - or else.
You do not get this feeling in Three hundred tonnes of aircraft, however exactly the same forces are at work, as can be seen in the many videos of crosswind landings of large jets. What the basic GA flying does in my opinion is give a pilot a basic feeling of anticipation of what the aircraft is about to try and do much faster than someone with no GA experience, and therefore allow them to react faster to stimuli.
I base this opinion on my knowledge of the behaviours of sailing boats - vessels that move in Two different fluid streams at once - wind and water, that are in many ways considerably harder to manoeuvre than aircraft, and the people that helm them.
I learned to sail at age 9. I have sailed more or less continuously for fifty years. I can say categorically that those that learned to sail in a little boat can sail a big one competently after instruction, much more competently than someone with no small boat experience.
It is very common in sailing to see a person come late to the art with no small boat experience, buy a very large, heavy and expensive vessel, acquire experienced crew, and instruction, then attempt to race it.
No matter how intelligent they are, no matter how much instruction is given, no matter how much money they throw at the boat (Five million is typical, and a million a year in expenses) it always ends in tears, because even the best of them is ALWAYS half a second or more behind the boat compared to an experienced dinghy sailor.
And Jetstar had a heavy landing? Surely that is getting behind the aircraft? Surely a botched approach is the same thing - getting behind the aircraft.
Of course there are "bad habits" in GA and operational skills that can be taught and learned, like the care and feeding of engines, navigation, etc., but the fact remains, how do you ensure that pilots don't get behind the aircraft? I don't think you can teach that in a large aircraft.
My gut feel is that the cadets schemes and "GA is not relevant" crowd are self serving arguments by those who want to drive costs down, and nothing else.
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Jetstar spokesman Simon Westaway said safety was the airline's priority and CASA regularly undertook such audits.
He said the audit ''delivered no formal request for corrective action into areas assessed''.
''Jetstar is currently formalising its integrated fatigue risk management system in accordance with best practice.''
He said the audit ''delivered no formal request for corrective action into areas assessed''.
''Jetstar is currently formalising its integrated fatigue risk management system in accordance with best practice.''
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Kelpie,
You show your true colours here mate. You're all mouth. You're part of the me, me, me, me, mob. The rest of the world should be perfect but not you.
It is part of the rules for the operation of the aircraft that a person who occupies an emergency exit row seat be willing and able to open the emergency exit doors. That's what they're there for. If you're not prepared to open the exit door then bugger off and give someone who is, the responsibility. In my experience most if not all 320 and 737 operators worldwide do the same thing, not just JQ. but any excuse to grandstand will do eh?
More to come MFA
Bugger that, any problem requiring an evacuation and I'm gone!!!
It is part of the rules for the operation of the aircraft that a person who occupies an emergency exit row seat be willing and able to open the emergency exit doors. That's what they're there for. If you're not prepared to open the exit door then bugger off and give someone who is, the responsibility. In my experience most if not all 320 and 737 operators worldwide do the same thing, not just JQ. but any excuse to grandstand will do eh?
More to come MFA
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From the kelpie
'I was not only asked to open the exit in the event of an emergency but rather assist the cabin crew and provide assistance for them to get out of the aircraft I'f necessary. Bugger that,'
My bold (and red). Clotted, don't think opening the emergency exit was the problem, rather doing their jobs is what may cause him to baulk. Don't see any grandstanding from my POV.
'I was not only asked to open the exit in the event of an emergency but rather assist the cabin crew and provide assistance for them to get out of the aircraft I'f necessary. Bugger that,'
My bold (and red). Clotted, don't think opening the emergency exit was the problem, rather doing their jobs is what may cause him to baulk. Don't see any grandstanding from my POV.
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Clotted
I did not say that I would not operate the emergency exit. What I said if you would take a moment to go back and read it is that I was asked by the single cabin crew in the centre if the aircraft to assist passengers by shouting directions and such. Even if need be, when I eventually leave the aircraft after all other passengers using that exit have gone, to make sure that the cabin crew was also able to leave the aircraft, otherwise to take her with me.
I just wonder how many pax actually listen to that special pax brief and understand exactly what they are asking?
IMHO most people have heard the standard 'operate the emergeny exit' Brief so many times they switch off.
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The Kelpie
I did not say that I would not operate the emergency exit. What I said if you would take a moment to go back and read it is that I was asked by the single cabin crew in the centre if the aircraft to assist passengers by shouting directions and such. Even if need be, when I eventually leave the aircraft after all other passengers using that exit have gone, to make sure that the cabin crew was also able to leave the aircraft, otherwise to take her with me.
I just wonder how many pax actually listen to that special pax brief and understand exactly what they are asking?
IMHO most people have heard the standard 'operate the emergeny exit' Brief so many times they switch off.
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The Kelpie
Last edited by The Kelpie; 18th Mar 2011 at 22:08.
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Sunfish,
That is BS, you still get the same "seat of your pants" feeling flying a big jet as you do flying a c152.
Only difference is it takes a bit of experience to recognise that feeling.
That is BS, you still get the same "seat of your pants" feeling flying a big jet as you do flying a c152.
Only difference is it takes a bit of experience to recognise that feeling.
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Well it's not just me that believes there is a problem and something is not quite adding up.
Jetstar contradicts CASA’s evidence to Senate inquiry
March 19, 2011 – 9:58 am, by Ben Sandilands
Jetstar’s reaction to the tabling of an unfavourable CASA audit of its rostering practices and fatigue management at the Senate inquiry into pilot training and airline safety yesterday contradicts the testimony given by CASA chief executive officer John McCormick.
In the Brisbane Times this morning this appears:
Jetstar spokesman Simon Westaway said safety was the airline’s priority and CASA regularly undertook such audits.He said the audit ”delivered no formal request for corrective action into areas assessed”.
”Jetstar is currently formalising its integrated fatigue risk management system in accordance with best practice.”
Yet John McCormick said:
…. that as a result of the combined audit and its recommendations being sent to Jetstar all of the those findings had been satisfactorily addressed by Jetstar.
Westaway doesn’t speak for Jetstar without his words being approved by the most senior levels of the airline. This is unlikely therefore to be a mistake, raising the question as to whether McCormick was mistaken.
Or whether McCormick is mindful of the relationship between major Australian carriers and the safety regulator to the point where documents that say in a direct manner that any of them aren’t properly managing safety issues are suppressed, edited, or otherwise defanged to avoid causing harm to the relationship.
There may be only one way that the dilemma created by Jetstar’s response can be* resolved in fairness to all parties.
That is, for the Senators to compare the human factors audit to the full audit document sent to Jetstar in May 2010.
Then, for the Senators to ask,* as some of them did yesterday, exactly what CASA required of Jetstar, exactly what Jetstar did in response, and exactly why CASA was then satisfied with the responses made by Jetstar which its spokesperson says they weren’t even asked to address and thus presumably never made.
These questions, and the resolution of the disparity in positions, is surely as critically important as Jetstar improperly changing the standard operating procedures for missed approaches on A320s, failing to keep any written records, failing to acknowledge its culpability in its Senate submission per Qantas, and leaving the pilots of one of its jets on July 27, 2007, so dangerously confused that they comes within metres of smashing the jet into the ground at Tullamarine Airport.
Jetstar is very proactive about throwing around the ‘proactive safety’ phrase. But it is very opaque and defensive, and at critical times, undocumented, when it comes proactively explaining actual events, processes and reasons concerning matters of direct relevance to its performance of regulatory obligations.
Its group CEO, Bruce Buchanan, should, with respect be begging the Senate to return and explain all of these matters, oh and a few concerning its apparent attempt to evade Australian labor laws and tax and superannuation obligations concerning its not-really-NZ New Zealand cadet pilot scheme and the offshoring of jobs and assets in Singapore.
It’s a wonderful opportunity for Jetstar to put the pro-active into ‘pro-active’ and talk these things through, one step at a time, without any flights to catch or weddings to attend or any other time pressures, in a Senate inquiry of vital interest to Australians beyond just those of air travellers.
March 19, 2011 – 9:58 am, by Ben Sandilands
Jetstar’s reaction to the tabling of an unfavourable CASA audit of its rostering practices and fatigue management at the Senate inquiry into pilot training and airline safety yesterday contradicts the testimony given by CASA chief executive officer John McCormick.
In the Brisbane Times this morning this appears:
Jetstar spokesman Simon Westaway said safety was the airline’s priority and CASA regularly undertook such audits.He said the audit ”delivered no formal request for corrective action into areas assessed”.
”Jetstar is currently formalising its integrated fatigue risk management system in accordance with best practice.”
Yet John McCormick said:
…. that as a result of the combined audit and its recommendations being sent to Jetstar all of the those findings had been satisfactorily addressed by Jetstar.
Westaway doesn’t speak for Jetstar without his words being approved by the most senior levels of the airline. This is unlikely therefore to be a mistake, raising the question as to whether McCormick was mistaken.
Or whether McCormick is mindful of the relationship between major Australian carriers and the safety regulator to the point where documents that say in a direct manner that any of them aren’t properly managing safety issues are suppressed, edited, or otherwise defanged to avoid causing harm to the relationship.
There may be only one way that the dilemma created by Jetstar’s response can be* resolved in fairness to all parties.
That is, for the Senators to compare the human factors audit to the full audit document sent to Jetstar in May 2010.
Then, for the Senators to ask,* as some of them did yesterday, exactly what CASA required of Jetstar, exactly what Jetstar did in response, and exactly why CASA was then satisfied with the responses made by Jetstar which its spokesperson says they weren’t even asked to address and thus presumably never made.
These questions, and the resolution of the disparity in positions, is surely as critically important as Jetstar improperly changing the standard operating procedures for missed approaches on A320s, failing to keep any written records, failing to acknowledge its culpability in its Senate submission per Qantas, and leaving the pilots of one of its jets on July 27, 2007, so dangerously confused that they comes within metres of smashing the jet into the ground at Tullamarine Airport.
Jetstar is very proactive about throwing around the ‘proactive safety’ phrase. But it is very opaque and defensive, and at critical times, undocumented, when it comes proactively explaining actual events, processes and reasons concerning matters of direct relevance to its performance of regulatory obligations.
Its group CEO, Bruce Buchanan, should, with respect be begging the Senate to return and explain all of these matters, oh and a few concerning its apparent attempt to evade Australian labor laws and tax and superannuation obligations concerning its not-really-NZ New Zealand cadet pilot scheme and the offshoring of jobs and assets in Singapore.
It’s a wonderful opportunity for Jetstar to put the pro-active into ‘pro-active’ and talk these things through, one step at a time, without any flights to catch or weddings to attend or any other time pressures, in a Senate inquiry of vital interest to Australians beyond just those of air travellers.
WRT the A320 T/S incident, I wasn't there but I dunno', personally I wouldn't even contemplate departing if I wasn't completely sure I wouldn't encounter a microburst. the fact that the crew requested information, were unable to elicit a response, and then decided to depart anyway has me more than just a little concerned.
About 6 months ago we waited on the ground at KSA for 90mins as a particularily nasty front moved through before we were convinced it was safe to depart. In that time there were no less than 3 runway changes! Now Krusty isn't particularily over cautious, but he has had enough scares in his previous G/A career to know when to go and when not to.
We all at some stage have lived and learnt. I'm sure this crew have learnt a valuable lesson and will use that hard won experience to good effect in the future. But, the cockpit of a Jet airliner is NOT the place to be learning such lessons!
Senators, are you listening.
About 6 months ago we waited on the ground at KSA for 90mins as a particularily nasty front moved through before we were convinced it was safe to depart. In that time there were no less than 3 runway changes! Now Krusty isn't particularily over cautious, but he has had enough scares in his previous G/A career to know when to go and when not to.
We all at some stage have lived and learnt. I'm sure this crew have learnt a valuable lesson and will use that hard won experience to good effect in the future. But, the cockpit of a Jet airliner is NOT the place to be learning such lessons!
Senators, are you listening.
That is BS, you still get the same "seat of your pants" feeling flying a big jet as you do flying a c152.
Only difference is it takes a bit of experience to recognise that feeling.
Only difference is it takes a bit of experience to recognise that feeling.
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So true! Because jets are so automated initially we tend to rely on instrument indications and autopilots wheras the seat of the pants flying still applies and is completely essential! Like the instructor told us in the sim on the endorsement, "it's just a f...ing aeroplane!".
In addition I've found I learn so much from the older generation, guys with tens of thousands of hours and decades behind them. Why? EXPERIENCE. You can't teach experience.
At 200 hours we are all extremely green. We know the basics with a licence, but it's a licence to learn. We learn on every flight. But a jetliner is no place to polish your basic flying skills and management of a flight. I'm sure insurance companies would love it. Bit why P-Plate drivers aren't allowed to drive high powered vehicles.
In addition I've found I learn so much from the older generation, guys with tens of thousands of hours and decades behind them. Why? EXPERIENCE. You can't teach experience.
At 200 hours we are all extremely green. We know the basics with a licence, but it's a licence to learn. We learn on every flight. But a jetliner is no place to polish your basic flying skills and management of a flight. I'm sure insurance companies would love it. Bit why P-Plate drivers aren't allowed to drive high powered vehicles.
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Quoting clotted...
So, I am in an emergency exit on a flight from Sydney to Perth, I've had a big day and decide to have a few as the missus is picking me up at the other end.
After about five beers and no lunch I am feeling a bit tipsy so I think I could go a few more.
My question clotted, I may be still willing but am I still able and who decides that I am no longer capable, or that I should move and where to on a full flight ?
It is part of the rules for the operation of the aircraft that a person who occupies an emergency exit row seat be willing and able to open the emergency exit doors. That's what they're there for.
After about five beers and no lunch I am feeling a bit tipsy so I think I could go a few more.
My question clotted, I may be still willing but am I still able and who decides that I am no longer capable, or that I should move and where to on a full flight ?
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Lets put the whole exit row thingy to rest as there are much bigger issues at hand:
1. SLF Type III exits were 'delegated' to pax use by proxy for no other reason other than to facilitate a reduce crew compliment (20:16:3)
2. The exemptions granted to JQ DJ & QF by CASA for their operation rely WHOLLY on the a/c manufacturers' claims that
a) pax can be briefed to operate them and;
b) the a/c can be evac'd within the magic 90 secs.
3. The conditions attached to the exemptions are very clear in respect of a compliant pax briefing HOWEVER - alcohol consumption is not a preclusion unless you are obviously franz list in which case you should not be on the a/c or should not have been served enough booze to get you that way- age, fatness (xtn seatbelt) and disability are.
4. CASA is SUPPOSED to have an active audit program especially in respect of exit row briefing compliance - however......it only happens on the way to other meetings typically....
5. The RENEWAL of exemptions is SUPPOSED to include review of practice and review of operators manual (but it does not - DJ's were renewed 'automatically)
6. IF you're in an exit row and you are not briefed correctly (ie the PAX has to open the exit as the CC are at opposite ends of the a/c) then ring REPCON and report it. Also inform the Cabin Manager inflight and ask him or her to please inform the Captain accordingly. (he might as well get started on the associated paperwork)
7. If you're in an exit row and you hear the crew using the 'e' word (or in DJ's simplified language coz Branson-speak always has to be different....) the phrase 'Get out' ..........then check safe to open, open the bloody exit, step onto the wing and get the hell away from the a/c.
As with just about everything else, the regulatory environment is the new frontier for cost cutting and CASA is the lazy old dog asleep on the verandah that doesn't want to bark too loudly.
Back to the serious stuff
AT
1. SLF Type III exits were 'delegated' to pax use by proxy for no other reason other than to facilitate a reduce crew compliment (20:16:3)
2. The exemptions granted to JQ DJ & QF by CASA for their operation rely WHOLLY on the a/c manufacturers' claims that
a) pax can be briefed to operate them and;
b) the a/c can be evac'd within the magic 90 secs.
3. The conditions attached to the exemptions are very clear in respect of a compliant pax briefing HOWEVER - alcohol consumption is not a preclusion unless you are obviously franz list in which case you should not be on the a/c or should not have been served enough booze to get you that way- age, fatness (xtn seatbelt) and disability are.
4. CASA is SUPPOSED to have an active audit program especially in respect of exit row briefing compliance - however......it only happens on the way to other meetings typically....
5. The RENEWAL of exemptions is SUPPOSED to include review of practice and review of operators manual (but it does not - DJ's were renewed 'automatically)
6. IF you're in an exit row and you are not briefed correctly (ie the PAX has to open the exit as the CC are at opposite ends of the a/c) then ring REPCON and report it. Also inform the Cabin Manager inflight and ask him or her to please inform the Captain accordingly. (he might as well get started on the associated paperwork)
7. If you're in an exit row and you hear the crew using the 'e' word (or in DJ's simplified language coz Branson-speak always has to be different....) the phrase 'Get out' ..........then check safe to open, open the bloody exit, step onto the wing and get the hell away from the a/c.
As with just about everything else, the regulatory environment is the new frontier for cost cutting and CASA is the lazy old dog asleep on the verandah that doesn't want to bark too loudly.
Back to the serious stuff
AT
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Kelpie
Loose Bruce won't go near the Committee Room unles he is forced to.
As for Westy's carefully worded comments in relation to JQ's FRMS ...........................
Interestingly Vaus has been issued with an exemption from CASA regarding duty limits which also references CC.......
Aside from the clear lack of wisdom on CASA's part the inclusion of the CC in the exemption seems like a precursor for some heavy patterns.
Any V drivers got a comment?
AT
Loose Bruce won't go near the Committee Room unles he is forced to.
As for Westy's carefully worded comments in relation to JQ's FRMS ...........................
Interestingly Vaus has been issued with an exemption from CASA regarding duty limits which also references CC.......
Aside from the clear lack of wisdom on CASA's part the inclusion of the CC in the exemption seems like a precursor for some heavy patterns.
Any V drivers got a comment?
AT
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airtags
Oh I think the next communication from the committee chairman will not have the word 'request' in it.
The Senators are going to want answers, the travelling public want and deserve answers.
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The Kelpie
Oh I think the next communication from the committee chairman will not have the word 'request' in it.
The Senators are going to want answers, the travelling public want and deserve answers.
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The Kelpie
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And Jetstar had a heavy landing? Surely that is getting behind the aircraft? Surely a botched approach is the same thing - getting behind the aircraft.
The best of them can get caught out with a heavy landing and the best of them can botch an approach and it ain't necessarily about getting behind the aircraft. In some cases it can be the result of poor decision making but it isn't always.