Air Niugini 737 overun at Guam
Sack the crew, remove their licenses and all the rest of it, is that going to do anything positive?
In other airlines pilots lose their jobs for minor SOP breaches, and this usually works at keeping others scared (including me) of losing their job or being demoted.
Air Niugini is safe as any other airline in the world.
Cheers - PLUGGA
Umm, no. They’re not.
Cheers - PLUGGA
Umm, no. They’re not.
So what does that do towards Just Culture?
Sledge hammer approach using punishment is certainly not the way to go IMHO, particularly having been an ex regulator as well both in PNG and Australia.
Plenty of talk on this forum in other areas with regards to the negatives relating to punishment, just do a search for Strict Liability!
Prove that allegation SO! We are all entitled to our own opinions however that’s a pretty bold statement without any evidence.....
Sledge hammer approach using punishment is certainly not the way to go IMHO, particularly having been an ex regulator as well both in PNG and Australia.
Plenty of talk on this forum in other areas with regards to the negatives relating to punishment, just do a search for Strict Liability!
Prove that allegation SO! We are all entitled to our own opinions however that’s a pretty bold statement without any evidence.....
Last edited by Duck Pilot; 19th Jul 2019 at 22:51.
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Just culture is a fantastic concept, but I cannot for the life of me see how it can be applied to this fatal crash.
"Just Culture is a culture in which front line operators or other persons are not punished for actions, omissions, or decisions taken by them, that are commensurate with their experience and training, but in which gross negligence, wilful violations and destructive acts are not tolerated".
The comment "Air Niugini is safe as any other airline in the world" is from years ago when you (Plugga) were a TNG CAPT, and I am sure that you would remember that the Check culture was tough (and in reality it needed to be).
But this crash proves that it was not safe at that point (one dead, several critical), and I'd suggest it the safety culture has been lacking for quite some time.
An example of lack of safety culture:
Rumour is is that the crash Captain was to be retrained as an FO on the B767, and the FO retrained for FO duty on the B737. It is further rumoured that it took the intervention of the incoming (now current) MD / CEO to cancel that idiotic decision, making the call that no retraining was to be made until the report was finalised. .
The AIC report is hugely critical of every aspect of both PX and PNG CASA (both of which you Plugga were involved with), so to call ANG as safe as any airline could be seen either as somewhat biased, living in a past life, or justifying the actions of friends.
I'd like to believe that ANG can rebuild and become a regarded airline once again, but to do so, Management need to understand that there is a certain skill set that needs to be there in the Flight Operations Department, certain experience is needed on the Flight Deck, and above all they need to be represented by a DECENT and STRONG manger that can stand up to the Political Masters that ANG simply fawns too and bends over for in such a sickening way.
"Just Culture is a culture in which front line operators or other persons are not punished for actions, omissions, or decisions taken by them, that are commensurate with their experience and training, but in which gross negligence, wilful violations and destructive acts are not tolerated".
The comment "Air Niugini is safe as any other airline in the world" is from years ago when you (Plugga) were a TNG CAPT, and I am sure that you would remember that the Check culture was tough (and in reality it needed to be).
But this crash proves that it was not safe at that point (one dead, several critical), and I'd suggest it the safety culture has been lacking for quite some time.
An example of lack of safety culture:
Rumour is is that the crash Captain was to be retrained as an FO on the B767, and the FO retrained for FO duty on the B737. It is further rumoured that it took the intervention of the incoming (now current) MD / CEO to cancel that idiotic decision, making the call that no retraining was to be made until the report was finalised. .
The AIC report is hugely critical of every aspect of both PX and PNG CASA (both of which you Plugga were involved with), so to call ANG as safe as any airline could be seen either as somewhat biased, living in a past life, or justifying the actions of friends.
I'd like to believe that ANG can rebuild and become a regarded airline once again, but to do so, Management need to understand that there is a certain skill set that needs to be there in the Flight Operations Department, certain experience is needed on the Flight Deck, and above all they need to be represented by a DECENT and STRONG manger that can stand up to the Political Masters that ANG simply fawns too and bends over for in such a sickening way.
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The term ‘no-blame culture’ flourished in the 1990s and still endures today. Compared to the largely punitive cultures that it sought to replace, it was clearly a step in the right direction. It acknowledged that a large proportion of unsafe acts were ‘honest errors’(the kinds of slips, lapses and mistakes that even the best people can make) and were not truly blameworthy, nor was there much in the way of remedial or preventative benefit to be had by punishing their perpetrators.
But the ‘no-blame’ concept had two serious weaknesses.
First, it ignored—or, at least, failed to confront—those individuals who wilfully (and often repeatedly) engaged in dangerous behaviours that most observers would recognise as being likely to increase the risk of a bad outcome.
Second, it did not properly address the crucial business of distinguishing between culpable and non-culpable unsafe acts.
In my view, a safety culture depends critically upon first negotiating where the line should be drawn between unacceptable behaviour and blameless unsafe acts. There will always be a grey area between these two extremes where the issue has to be decided on a case by case basis. This is where the guide-lines provided by A Roadmap to a Just Culture will be of great value. A number of aviation organisations have embarked upon this process, and the general indications are that only around 10 per cent of actions contributing to bad events are judged as culpable. In principle, at least, this means that the large majority of unsafe acts can be reported without fear of sanction. Once this crucial trust has been established, the organisation begins to have a reporting culture, something that provides the system with an accessible memory, which, in turn, is the essential underpinning to a learning culture. There will, of course, be setbacks along the way. But engineering a just culture is the all-important early step; so much else depends upon it.
James Reason
But the ‘no-blame’ concept had two serious weaknesses.
First, it ignored—or, at least, failed to confront—those individuals who wilfully (and often repeatedly) engaged in dangerous behaviours that most observers would recognise as being likely to increase the risk of a bad outcome.
Second, it did not properly address the crucial business of distinguishing between culpable and non-culpable unsafe acts.
In my view, a safety culture depends critically upon first negotiating where the line should be drawn between unacceptable behaviour and blameless unsafe acts. There will always be a grey area between these two extremes where the issue has to be decided on a case by case basis. This is where the guide-lines provided by A Roadmap to a Just Culture will be of great value. A number of aviation organisations have embarked upon this process, and the general indications are that only around 10 per cent of actions contributing to bad events are judged as culpable. In principle, at least, this means that the large majority of unsafe acts can be reported without fear of sanction. Once this crucial trust has been established, the organisation begins to have a reporting culture, something that provides the system with an accessible memory, which, in turn, is the essential underpinning to a learning culture. There will, of course, be setbacks along the way. But engineering a just culture is the all-important early step; so much else depends upon it.
James Reason
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Just culture is a fantastic concept, but I cannot for the life of me see how it can be applied to this fatal crash.
"Just Culture is a culture in which front line operators or other persons are not punished for actions, omissions, or decisions taken by them, that are commensurate with their experience and training, but in which gross negligence, wilful violations and destructive acts are not tolerated".
"Just Culture is a culture in which front line operators or other persons are not punished for actions, omissions, or decisions taken by them, that are commensurate with their experience and training, but in which gross negligence, wilful violations and destructive acts are not tolerated".
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Seriously continuing the approach with the GPWS warnings going off a lot and then crashing (and that is what it is) means that Just culture is not applicable in this case.
Air Niugini is safe as any other airline in the world.
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"What we have to understand here is the pilots didn't purposely fly that plane into the water," Air Niugini's managing director Alan Milne told reporters, after the findings were handed down
Gee I don't think any lucid pilot intentionally trys to fly into the ground/water !!
So thats ok then, invite the boys up for tea and biccies ,tell them we have something called sop and that you really should follow them because,well , you just should.
Now off you go and try not to do something like that again hmm
Agree with some of your comments NCD, these kind of accidents relating to pilots intentionally breaking hard rules aren’t only related to ANG. There are a couple of other recent accidents that have occurred in PNG where the Captains had pushed on and ended up killing themselves and others.
The check and training standards certainly were tough when I was on the Dash with ANG. A failed check actually triggered my departure, which most people would be aware of, however on reflection after the dust had settled I was actually very grateful for the Checkie’s decision on the day to fail me, as it has made me a better pilot with regards to how I interpret and apply standards.
The check and training standards certainly were tough when I was on the Dash with ANG. A failed check actually triggered my departure, which most people would be aware of, however on reflection after the dust had settled I was actually very grateful for the Checkie’s decision on the day to fail me, as it has made me a better pilot with regards to how I interpret and apply standards.
If I read the report correctly, the passenger who tragically died wasn't wearing his seat belt, and the resulting blunt trauma he suffered was a cause of death. Do Air Nuigini cabin crew check that pax have their belts done up?
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There is something screwy with the animation. It shows no thrust mode annunciation, then changes to FMC SPEED just before 2,500’. At that time VNAV PATH drops out, the change box shows, but is empty. There is no vertical mode annunciation from that point onwards. The commander speed setting shows ‘0’ until below the minima & changes from 0 to 139kts at that time. There are no FMC derived speed bugs for the flap settings. Also, ROLLOUT briefly shows just before they hit the water. That was with FD displayed, as the autopilot had been disengaged. It should only be displayed on an auto land. The indicated altitude is below the rad alt & they are over water, so one wonders if the QNH is correct. And finally, the video shows all the MCP displays flashing, which is not normal.
Maybe their setup is different to ones I fly, but it does look a bit screwy.
Maybe their setup is different to ones I fly, but it does look a bit screwy.
Just Culture???
I’m not defending the crew, whilst they must totally accept responsibility for their own actions, we must be cognisant of the fact that quite a lot of other people and organisations determined that both the pilots were apparently trained and suitably experienced to operate the aircraft before the sequence of events that led up to this accident.
As I stated above, we (those within the PNG aviation community) must take some responsibility to drum out this so called culture of busting hard minimums. I’ve seen it myself in the GA sector in PNG, now it’s obviously crept into ANG due to reasons as mentioned by NCD. Break a fundamental rule in PNG, you are likely to die as there are no second chances as most us all well known.
Have a look at the P2-TAA accident report, it’s a shocker with many parallels in relation to the root cause of this accident. The Captain totally ignored his co-pilot and pushed on with disastrous results.
I’m not defending the crew, whilst they must totally accept responsibility for their own actions, we must be cognisant of the fact that quite a lot of other people and organisations determined that both the pilots were apparently trained and suitably experienced to operate the aircraft before the sequence of events that led up to this accident.
As I stated above, we (those within the PNG aviation community) must take some responsibility to drum out this so called culture of busting hard minimums. I’ve seen it myself in the GA sector in PNG, now it’s obviously crept into ANG due to reasons as mentioned by NCD. Break a fundamental rule in PNG, you are likely to die as there are no second chances as most us all well known.
Have a look at the P2-TAA accident report, it’s a shocker with many parallels in relation to the root cause of this accident. The Captain totally ignored his co-pilot and pushed on with disastrous results.
Last edited by Duck Pilot; 21st Jul 2019 at 11:51.
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Duck
I think you are being overly generous.
If true the previous day warning calls were ignored there's a picture starting to build of a consistant attitude by the PIC, not just a "one off" or a "bad day at the office".
It was done with intent, this time he didn't get away with it - and somone died.
Personally find it hard any idea that you "reward" someone for such a result by keeping their job.
Equally can't see how the airline could ever imagine allowing him to continue - he with intent deliberately operated outside the company SOP's/standards - and someone died.
Equally can't see how the regulator hasn't suspended or cancelled his licence - same as above.
The F/O - making absolutely NO calls, apparently having NO awareness of the increadibly dangerous situation speaks either of poor standards or poor checking or intimidation, as the same F/O as previous day unfortunately a negative picture starts to build.
Saving grace - not the PIC so intensive retraining/checking probably a toss of the coin whether perceived as deserved or not.
One only hopes the regulator has the resources to pull whatever data they can from the airline to see how much this was a one off incident/individual or indicitive of a greater attitude tolerated, if not encouraged, by Flight Ops Management and act accordingly.
One also hopes they have the desire and freedom to do the same.
I think you are being overly generous.
If true the previous day warning calls were ignored there's a picture starting to build of a consistant attitude by the PIC, not just a "one off" or a "bad day at the office".
It was done with intent, this time he didn't get away with it - and somone died.
Personally find it hard any idea that you "reward" someone for such a result by keeping their job.
Equally can't see how the airline could ever imagine allowing him to continue - he with intent deliberately operated outside the company SOP's/standards - and someone died.
Equally can't see how the regulator hasn't suspended or cancelled his licence - same as above.
The F/O - making absolutely NO calls, apparently having NO awareness of the increadibly dangerous situation speaks either of poor standards or poor checking or intimidation, as the same F/O as previous day unfortunately a negative picture starts to build.
Saving grace - not the PIC so intensive retraining/checking probably a toss of the coin whether perceived as deserved or not.
One only hopes the regulator has the resources to pull whatever data they can from the airline to see how much this was a one off incident/individual or indicitive of a greater attitude tolerated, if not encouraged, by Flight Ops Management and act accordingly.
One also hopes they have the desire and freedom to do the same.
Last edited by galdian; 21st Jul 2019 at 07:46. Reason: clarification
The crew were in a system, not only the ANG C&T system hence my previous. Tear up the pilot’s licences and deam them never to fly again. Ok problem solved???????
Is that the ultimate answer, in my opinion no. There is an elephant in the room, I can certainly see it however some commenting here certainly can’t....
Then believe the regulator will provide the golden bullet to correct the problem, obviously some people commenting here have never been to PNG.
Another White Tin please nurse!
Is that the ultimate answer, in my opinion no. There is an elephant in the room, I can certainly see it however some commenting here certainly can’t....
Then believe the regulator will provide the golden bullet to correct the problem, obviously some people commenting here have never been to PNG.
Another White Tin please nurse!
Last edited by Duck Pilot; 21st Jul 2019 at 10:46.