Norfolk Island Ditching ATSB Report - ?
Creampuff. I won't speak for CASA or ATSB but just for a moment reflect just on Airservices. If what you say is true i.e. "no longer have the critical mass of knowledge, skills and attitude to identify and resolve them on their own initiative" and they have so much trouble with an interesting permutation of responsibility of FIS WX provision, how do you think they might be going with core service provision, like conflict detection, resolution and monitoring?
Given significantly increasing traffic, an increasingly worrisome age demographic of remaining controllers and essentially no new system to replace TAAATS, many inside Airservices are identifying a "perfect storm" between now and when ever AFS/CMATS might be commissioned and then presumably many years after provides a more automated capability than TAAATS. Perhaps Ben Sandilands is closer to the mark than many think. Many people outside Airservices would be surprised how "manual" and human centric the ATC system is as Ben tries often in vain to identify. Interestingly as you have suggested many seem to have confused Heffernan's frustration with his usual form, this time I'm not so sure. If you carefully watched the Senate streamed video of that day, there was more than just Heffernan who were shaking their heads!
In a strange turn of events, many of Airservices managers' harshest critics are now showing those same managers great sympathy after the Senate bashing. From my perspective just this week has certainly brought forward some very interesting opinions mostly based on 20th century paradigms and seemingly lacking common sense and a core misunderstanding of why the senators were so aghast.
Given significantly increasing traffic, an increasingly worrisome age demographic of remaining controllers and essentially no new system to replace TAAATS, many inside Airservices are identifying a "perfect storm" between now and when ever AFS/CMATS might be commissioned and then presumably many years after provides a more automated capability than TAAATS. Perhaps Ben Sandilands is closer to the mark than many think. Many people outside Airservices would be surprised how "manual" and human centric the ATC system is as Ben tries often in vain to identify. Interestingly as you have suggested many seem to have confused Heffernan's frustration with his usual form, this time I'm not so sure. If you carefully watched the Senate streamed video of that day, there was more than just Heffernan who were shaking their heads!
In a strange turn of events, many of Airservices managers' harshest critics are now showing those same managers great sympathy after the Senate bashing. From my perspective just this week has certainly brought forward some very interesting opinions mostly based on 20th century paradigms and seemingly lacking common sense and a core misunderstanding of why the senators were so aghast.
That’s precisely the source of the Chair’s frustration with the witnesses from Airservices.
ATSB report should have covered the FIS issue and made a Safety Recommendation to close the loop is one existed.
However, this is pretty clear
ATS Communications Facilities
FIS Auckland SP6 INTL HF 13261 17904 3467 5643 8867 WI SELCAL
So NZ AIP infers that they do not provide ATS service (including FIS) at YSNF, AUS AIP (ERSA) says FIS provided by Auckland.
Last edited by missy; 24th Nov 2012 at 06:12.
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YSNF - asa"s ERSA
The following is page 2 of ersa:
Note:
1. AIP Australia
2. Descent requirements for YSNF
The pilot , from ersa, must assume that in compliance with ersa [asa] at FAC N-2 that AUK only provides a "service" for asa. Also, the flight plan has been lodged with BN centre - Job's right!!
Let's get the responsibility right.
Note:
1. AIP Australia
2. Descent requirements for YSNF
The pilot , from ersa, must assume that in compliance with ersa [asa] at FAC N-2 that AUK only provides a "service" for asa. Also, the flight plan has been lodged with BN centre - Job's right!!
Let's get the responsibility right.
I think the Chair was peeved when the committee realised the flight NEVER entered Australian airspace ...
I think the Chair was 'peeved' because it appeared that no one in Airservices seemed to understand or be concerned to resolve, quickly, the apparent uncertainty as to who is responsible for ensuring that aircraft inbound to the Australian external territory of Norfolk Island receive adequate and timely information about the weather there.
Given significantly increasing traffic, an increasingly worrisome age demographic of remaining controllers and essentially no new system to replace TAAATS, many inside Airservices are identifying a "perfect storm" between now and when ever AFS/CMATS might be commissioned and then presumably many years after provides a more automated capability than TAAATS.
Perhaps Ben Sandilands is closer to the mark than many think. Many people outside Airservices would be surprised how "manual" and human centric the ATC system is as Ben tries often in vain to identify. Interestingly as you have suggested many seem to have confused Heffernan's frustration with his usual form, this time I'm not so sure. If you carefully watched the Senate streamed video of that day, there was more than just Heffernan who were shaking their heads!
In a strange turn of events, many of Airservices managers' harshest critics are now showing those same managers great sympathy after the Senate bashing. From my perspective just this week has certainly brought forward some very interesting opinions mostly based on 20th century paradigms and seemingly lacking common sense and a core misunderstanding of why the senators were so aghast.
Last edited by Creampuff; 25th Nov 2012 at 04:44.
That's why I'll be very interested to find out who it was that decided shutting down the FSU on Norfolk was a good idea
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Safety first!
Frank,
Mate, don't let anybody bait you into firing up. All that will happen is you cop a ban.
Remember Frank when some Politicians are on the ropes they will throw mud at the opponents, point the finger, dig up some old dirt, anything to deflect the heat from themselves. Sometimes pprune operates the same way. Sometimes.
Mate, don't let anybody bait you into firing up. All that will happen is you cop a ban.
Remember Frank when some Politicians are on the ropes they will throw mud at the opponents, point the finger, dig up some old dirt, anything to deflect the heat from themselves. Sometimes pprune operates the same way. Sometimes.
Last edited by gobbledock; 25th Nov 2012 at 05:28.
That's pretty obvious. Close down the lot of them to save, what was it, $20m a year? ATC can do it all. Unicoms are the way of the world. If you want the service, you pay for it. Closing down FS has saved us $1b, hasn't it?
But why, then, would Airservices have any hesitation in saying that the shutdown of an FSU (on an Island a loooong way into the deep blue sea and with notoriously unpredictable weather issues) was "Dick's idea"?
But why, then, would Airservices have any hesitation in saying that the shutdown of an FSU (on an Island a loooong way into the deep blue sea and with notoriously unpredictable weather issues) was "Dick's idea"?
What troubles me is that if the ATSB hadn't had this change in ideology (that dates back 4 years) which limits the 'scope' of their investigations and inhibits the issueing of SRs this 'discrepancy' may well have been captured three years earlier and there now may have been action to address this safety issue!
The question that has to be asked is why have the ATSB if they are no longer an independent 'safety' watchdog!
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The question that has to be asked is why have the ATSB if they are no longer an independent 'safety' watchdog!
Senator FAWCETT: Chair, given the inquiry on Monday I do not actually have a huge number of questions, except to follow up something with Mr Mrdak. Last time we fspoke about closing the loop between ATSB recommendations and CASA following through with regulation as a consequential change within a certain time frame. The view was expressed that it was not necessarily a departmental role to have that closed loop system. I challenged that at the time. I just welcome any comment you may have three or four months down the track as to whether there has been any further thought within your department as to how we make sure we have a closed loop system for recommendations that come out of the ATSB.
Mr Mrdak : It is something we are doing further work on in response to your concerns. We recognise that we do need to ensure the integrity of the investigatory response and then the regulatory response. So it is something we are looking at closely. I and the other chief executives in the portfolio will do some further work on that area.
Senator FAWCETT: Do you have a time frame on when you might be able to report back to the committee?
Mr Mrdak : Not as yet. I will come back to you on notice with some more detail.
Senator FAWCETT: If I could invite you to come back to the chair perhaps with a date for a briefing to the committee, outside of the estimates process, as to how you might implement that.
Mr Mrdak : Yes.
Senator FAWCETT: Because the work by ATSB is almost nugatory if you do not have a closed loop system that makes sure it is implemented in a timely manner.
Mr Mrdak : It is something we are doing further work on in response to your concerns. We recognise that we do need to ensure the integrity of the investigatory response and then the regulatory response. So it is something we are looking at closely. I and the other chief executives in the portfolio will do some further work on that area.
Senator FAWCETT: Do you have a time frame on when you might be able to report back to the committee?
Mr Mrdak : Not as yet. I will come back to you on notice with some more detail.
Senator FAWCETT: If I could invite you to come back to the chair perhaps with a date for a briefing to the committee, outside of the estimates process, as to how you might implement that.
Mr Mrdak : Yes.
Senator FAWCETT: Because the work by ATSB is almost nugatory if you do not have a closed loop system that makes sure it is implemented in a timely manner.
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Survivability Equipment
I wonder has PEL-AIR raised an SDR about the failings of the jackets and raft location? Also, I cant see that CASA has issued any industry advice regarding the failures. If the ATSB don't think its relevant, who does??? I hope the FAA are watching this process. It's a race to the bottom here now. PAN PAN PAN ALBO - DO SOMETHING!
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ATSB Mmmmmm
Spot on SARCS, why the hell was this not consulted or advised? Then again, how well would Beaker do confronting the industry! Lots of big eyes, staring at the ceiling, and hand movements, both horizontal and vertical! Put paddles in his hands and he could do ramp parking guidance!
When did the ATSB decide to focus on specific parts of accidents? That in itself doesn't match with the TSI Act or Annex 13!
I hear the 3 Amigo's (Q, A & D) have more coming that is capital B.A.D. Bring it on. Also, more pawns ready to "chat" to the Senate about malfeasance.
Simply put, in an accident like this, how can:
ATC
Weather forecasting
Comms
Crash Survivability
ORG issues
Regulatory issues
CRM
Fatigue Risk Management
Aircraft performance
not be adequately covered in the ATSB analysis? Maybe someone in CASA can answer that.
How many jets have ditched, at night, in open water, in zero visibility? Getting the recorders should have been a priority. Then there'd be no assumptions about fuel. My money is on the Davies submission. Beaker and his minions have a clue.
I hear Karen Casey (the flight nurse) is in a bad way, without a cent from PEL-AIR yet!
APPALLING!
Then again, you could only imagine What troubles me is that if the ATSB hadn't had this change in ideology (that dates back 4 years) which limits the 'scope' of their investigations and inhibits the issueing of SRs this 'discrepancy' may well have been captured three years earlier and there now may have been action to address this safety issue!
The question that has to be asked is why have the ATSB if they are no longer an independent 'safety' watchdog!
I hear the 3 Amigo's (Q, A & D) have more coming that is capital B.A.D. Bring it on. Also, more pawns ready to "chat" to the Senate about malfeasance.
Simply put, in an accident like this, how can:
ATC
Weather forecasting
Comms
Crash Survivability
ORG issues
Regulatory issues
CRM
Fatigue Risk Management
Aircraft performance
not be adequately covered in the ATSB analysis? Maybe someone in CASA can answer that.
How many jets have ditched, at night, in open water, in zero visibility? Getting the recorders should have been a priority. Then there'd be no assumptions about fuel. My money is on the Davies submission. Beaker and his minions have a clue.
I hear Karen Casey (the flight nurse) is in a bad way, without a cent from PEL-AIR yet!
APPALLING!
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Mr Mrdak
Halfman.......quotes:
Mrdak says it is something they are doing further on, yet he has no timeframe! How about this - "Senator you caught me with my pants down, but we'll look into it"! Classic bureaucratic response!
Well done MrDak! Dig the Skull and Beaker out of this hole!
Senator FAWCETT: Chair, given the inquiry on Monday I do not actually have a huge number of questions, except to follow up something with Mr Mrdak. Last time we fspoke about closing the loop between ATSB recommendations and CASA following through with regulation as a consequential change within a certain time frame. The view was expressed that it was not necessarily a departmental role to have that closed loop system. I challenged that at the time. I just welcome any comment you may have three or four months down the track as to whether there has been any further thought within your department as to how we make sure we have a closed loop system for recommendations that come out of the ATSB.
Mr Mrdak : It is something we are doing further work on in response to your concerns. We recognise that we do need to ensure the integrity of the investigatory response and then the regulatory response. So it is something we are looking at closely. I and the other chief executives in the portfolio will do some further work on that area.
Senator FAWCETT: Do you have a time frame on when you might be able to report back to the committee?
Mr Mrdak : Not as yet. I will come back to you on notice with some more detail.
Mr Mrdak : It is something we are doing further work on in response to your concerns. We recognise that we do need to ensure the integrity of the investigatory response and then the regulatory response. So it is something we are looking at closely. I and the other chief executives in the portfolio will do some further work on that area.
Senator FAWCETT: Do you have a time frame on when you might be able to report back to the committee?
Mr Mrdak : Not as yet. I will come back to you on notice with some more detail.
Well done MrDak! Dig the Skull and Beaker out of this hole!
Last edited by Jinglie; 25th Nov 2012 at 12:32.
Well done Jinglie you nailed at least one of the elephants in the room...but I fear there is a stampede of more to come...
To be fair to Beaker he has only been in the job 3 1/2 years which kind of suggests that was the brief he was given from Mrdak and hence the Minister. The following remark is kind of telling:
Mr Dolan: The mechanism we have arrived at, which seems to work well, is one that looks to identify the shape of issues as early as possible and to get them sufficiently clear so that the relevant party can start proactively doing something about them before the investigation is even complete.
Is that the royal "we" or whom does the "we" include?
"which seems to work well"...whom does it work well for? Obviously not the world wide industry or the victims. On what basis does Beaker base that assessment?
Jinglie said: Spot on SARCS, why the hell was this not consulted or advised? Then again, how well would Beaker do confronting the industry! Lots of big eyes, staring at the ceiling, and hand movements, both horizontal and vertical! Put paddles in his hands and he could do ramp parking guidance!
Mr Dolan: The mechanism we have arrived at, which seems to work well, is one that looks to identify the shape of issues as early as possible and to get them sufficiently clear so that the relevant party can start proactively doing something about them before the investigation is even complete.
"which seems to work well"...whom does it work well for? Obviously not the world wide industry or the victims. On what basis does Beaker base that assessment?
The mechanism we have arrived at, which seems to work well, is one that looks to identify the shape of issues as early as possible and to get them sufficiently clear so that the relevant party can start proactively doing something about them before the investigation is even complete.
We jump to an early conclusion and then complete an investigation. Having identified the ‘shape’ of issues early, we don’t need to investigate matters that might not support our early conclusion.
It seems to work well because the investigation invariably finds material to support the early conclusion.
Ben's latest plus a comment is pretty much a rehash of the conclusions most people (besides the Flat Earth Society award recipients) have thoughtfully posted here:
Good job Ben!
ATSB 'leads' air safety into a retreat from Reason? | Plane Talking
ATSB ‘leads’ air safety into a retreat from Reason?
Ben Sandilands | Nov 26, 2012 12:08PM | EMAIL | PRINT
The Hansard record has caught Australia’s air safety authority diminishing the role of James Reason in crash causes, raising more questions about how far it will go to cover up deficiencies in CASA’s oversight of air ambulance operator Pel-Air
Has Australia been dragged back toward the dark ages in air accident investigations in order to cover up gross deficiencies in the performance and professional integrity of CASA, the air safety regulator?
There is a section of the testimony given by Martin Dolan, the chief commissioner of the ATSB, the investigating authority, to a Senate inquiry last week that suggests this is the case.
The Senate committee concerned was inquiring into the final report issued by the ATSB on 30 August into the ditching of a Pel-Air Careflight air ambulance charter near Norfolk Island on 18 November 2009.
This is the critical passage of that hearing, last Wednesday, as reported in Hansard, which can be found in full at the inquiry’s web page under transcripts.
Mr Dolan: We see our job as a different job from CASA’s. The special audit was in relation to CASA’s views about how Pel-Air complied with regulatory provisions. That is their responsibility as the regulator. We wanted to understand what risks existed in the system as it stood that needed attention and were ongoing risks to safety. We did that through our investigation and the material we acquired.
Senator XENOPHON: Given what you have conceded—that the special audit report contained information that could go to systemic issues, the sorts of issues which were raised very well by Senator Fawcett at previous hearings—could that have been relevant for the purpose of the ATSB’s final report?
Mr Dolan: That is possible. The only point I would make in response to this is the broad context in which we were undertaking our investigation. There were a range of things. If we want to go to Professor Reason’s model of investigation—though we think we have come a long way since Professor Reason’s initial work in the 1990s—there is error and there is violation.
While the focus of our investigations is on error and understanding error—how to prevent it, how to detect it and how to deal with its consequences—there was also in this case an element of what, in Professor Reason’s model, would be viewed as violation; and that is principally the responsibility of the regulator.
Professor James Reason is the UK psychologist whose work in the causes of preventable accidents, in aviation, and industry and health care more broadly, both revolutionised and underpins to this day the methodology of air safety investigations and safety enhancement. He is often credited for enunciating the Swiss cheese model for accident causes, where a range of issues, each of them insufficient to cause a crash on their own, align, like the holes in the cheese, allowing a disaster to occur.
To have it demeaned in the manner that it was in the Senate inquiry, without any obvious reason other than an unannounced policy retreat by the ATSB in order to protect CASA from being exposed as derelict and incompetent in the discharge of its duties of care and oversight is to be blunt, a national disgrace and embarrassment.
The Minister responsible for both CASA, and the supposedly independent safety investigator, Anthony Albanese, is a busy man. He appears to be too busy to deal with these issues, other than to brush off through a spokesperson any suggestion that the ATSB ought to have, at the least, told him it was changing its supposedly world leading methodology to avoid issuing safety recommendations, the function which the rest of the world, and Australian air operators, actually rely upon to be alerted to issues which may be of wider relevance to their activities than Pel-Air alone.
Those unannounced policy changes by the ATSB resulted in a report which makes no reference to a special CASA audit of Pel-Air that found it unsafe in its Careflight operations at the time of the accident through multiple breaches of the applicable aviation rules.
The focus on errors rather than violations by the operating company also produced a report that cast no light on fatigue issues, or the failure of air traffic control to pass on a warning of a serious deterioration in forecast conditions for the arrival of the jet at Norfolk Island, or pilot fatigue, or the suitability of the jet to even embark on the mission it was flying, or the failure of all of the safety equipment on board.
It makes no reference to the disclosure in the CASA audit to the lack of fuel planning guidance by the operator Pel-Air for the Westwinds in its fleet, nor to glaring discrepancies between what CASA had discovered about the operator in previous audits compared to what it uncovered after the loss of the jet in question.
The report effectively suppressed disclosure of significant concerns within CASA over regulatory confusion as to whether such flights should turn back or press on when conditions deteriorated on charters such as the one that crashed.
The real danger in the situation touched upon by Dolan however, is that Australia has allowed its two aviation bodies to trash the standards of disclosure, enforcement and investigation that its public, and its air operators, and the rest of the world wide aviation safety community, previously took for granted.
Dolan’s attempt to distinguish between “error” and “violation” reinforces CASA’s move away from Reason’s model, which has been underway for quite some time.
The rhetorical expression of the New World Order is “Just Culture,” which you can see bandied about quite a bit, particularly in the way CASA approaches smaller operators, where it’s emphasised as a rationale for emphasis on training and management of human factors.
The theory goes like this:
Errors are understandable and inevitable, and addressed in the now traditional way via Reason’s model.
Alongside errors, however, are cases where humans involved in safety systems have understood the rules, and have made conscious decisions which have had the effect of violating them.
A common example used to illustrate that is the hypothetical pilot who crashes into a power line while doing a low pass over his girlfriend’s house: Fully aware of the rules and safety implications, but deciding to ignore them.
The sports aviation bodies have been increasingly been all over this in recent years. RAAus now has human factors modules incorporated into its training syllabus well in advance of anything that a CASA pilot will encounter (to the extent that CASA license holders wishing to acquire RAAus credentials are now required to undergo additional training)
In a “just culture,” errors would be addressed through training, enhancements to safety systems, etc; But violations would be punished, because it isn’t “just” to have people running around breaking rules all the time without some kind of regulatory response. Moreover, there are very few safety lessons to be learned from violations that haven’t been learned thousands of times already (“Oh, look, yet another idiot hit a power line and turned himself into a lawn dart.”), so the safety messages arising from them are muted and the punishment is emphasised instead.
It seems to me that in the Pel-Air case, the ATSB has decided that the pilot was aware of rules pertaining to refuelling, oceanic weather, selection of alternates, etc; and chose to proceed anyway.
So in the “just culture” model, that’s a violation, not an error; and ought to be punished, not understood. The fact that the pilot made the decisions he made in the context of his employer’s safety systems (or lack thereof) loses importance.
It seems to me that if this continues, we’ll be on a path towards the bad old days of holding people criminally liable for accidents/incidents. The effect of that on safety is well understood: Liability-conscious individuals will neglect to report incidents, no lessons will be learned from unreported free-kicks, and accident rates will consequently increase.
If the Government is serious about its “just culture” efforts, it needs to apply a bit more maturity and depth to its execution. Reflexively dumping on pilots following multi-causal accidents isn’t going to get us anywhere useful.
Ben Sandilands | Nov 26, 2012 12:08PM | EMAIL | PRINT
The Hansard record has caught Australia’s air safety authority diminishing the role of James Reason in crash causes, raising more questions about how far it will go to cover up deficiencies in CASA’s oversight of air ambulance operator Pel-Air
Has Australia been dragged back toward the dark ages in air accident investigations in order to cover up gross deficiencies in the performance and professional integrity of CASA, the air safety regulator?
There is a section of the testimony given by Martin Dolan, the chief commissioner of the ATSB, the investigating authority, to a Senate inquiry last week that suggests this is the case.
The Senate committee concerned was inquiring into the final report issued by the ATSB on 30 August into the ditching of a Pel-Air Careflight air ambulance charter near Norfolk Island on 18 November 2009.
This is the critical passage of that hearing, last Wednesday, as reported in Hansard, which can be found in full at the inquiry’s web page under transcripts.
Mr Dolan: We see our job as a different job from CASA’s. The special audit was in relation to CASA’s views about how Pel-Air complied with regulatory provisions. That is their responsibility as the regulator. We wanted to understand what risks existed in the system as it stood that needed attention and were ongoing risks to safety. We did that through our investigation and the material we acquired.
Senator XENOPHON: Given what you have conceded—that the special audit report contained information that could go to systemic issues, the sorts of issues which were raised very well by Senator Fawcett at previous hearings—could that have been relevant for the purpose of the ATSB’s final report?
Mr Dolan: That is possible. The only point I would make in response to this is the broad context in which we were undertaking our investigation. There were a range of things. If we want to go to Professor Reason’s model of investigation—though we think we have come a long way since Professor Reason’s initial work in the 1990s—there is error and there is violation.
While the focus of our investigations is on error and understanding error—how to prevent it, how to detect it and how to deal with its consequences—there was also in this case an element of what, in Professor Reason’s model, would be viewed as violation; and that is principally the responsibility of the regulator.
Professor James Reason is the UK psychologist whose work in the causes of preventable accidents, in aviation, and industry and health care more broadly, both revolutionised and underpins to this day the methodology of air safety investigations and safety enhancement. He is often credited for enunciating the Swiss cheese model for accident causes, where a range of issues, each of them insufficient to cause a crash on their own, align, like the holes in the cheese, allowing a disaster to occur.
To have it demeaned in the manner that it was in the Senate inquiry, without any obvious reason other than an unannounced policy retreat by the ATSB in order to protect CASA from being exposed as derelict and incompetent in the discharge of its duties of care and oversight is to be blunt, a national disgrace and embarrassment.
The Minister responsible for both CASA, and the supposedly independent safety investigator, Anthony Albanese, is a busy man. He appears to be too busy to deal with these issues, other than to brush off through a spokesperson any suggestion that the ATSB ought to have, at the least, told him it was changing its supposedly world leading methodology to avoid issuing safety recommendations, the function which the rest of the world, and Australian air operators, actually rely upon to be alerted to issues which may be of wider relevance to their activities than Pel-Air alone.
Those unannounced policy changes by the ATSB resulted in a report which makes no reference to a special CASA audit of Pel-Air that found it unsafe in its Careflight operations at the time of the accident through multiple breaches of the applicable aviation rules.
The focus on errors rather than violations by the operating company also produced a report that cast no light on fatigue issues, or the failure of air traffic control to pass on a warning of a serious deterioration in forecast conditions for the arrival of the jet at Norfolk Island, or pilot fatigue, or the suitability of the jet to even embark on the mission it was flying, or the failure of all of the safety equipment on board.
It makes no reference to the disclosure in the CASA audit to the lack of fuel planning guidance by the operator Pel-Air for the Westwinds in its fleet, nor to glaring discrepancies between what CASA had discovered about the operator in previous audits compared to what it uncovered after the loss of the jet in question.
The report effectively suppressed disclosure of significant concerns within CASA over regulatory confusion as to whether such flights should turn back or press on when conditions deteriorated on charters such as the one that crashed.
The real danger in the situation touched upon by Dolan however, is that Australia has allowed its two aviation bodies to trash the standards of disclosure, enforcement and investigation that its public, and its air operators, and the rest of the world wide aviation safety community, previously took for granted.
- Mark Newton
Dolan’s attempt to distinguish between “error” and “violation” reinforces CASA’s move away from Reason’s model, which has been underway for quite some time.
The rhetorical expression of the New World Order is “Just Culture,” which you can see bandied about quite a bit, particularly in the way CASA approaches smaller operators, where it’s emphasised as a rationale for emphasis on training and management of human factors.
The theory goes like this:
Errors are understandable and inevitable, and addressed in the now traditional way via Reason’s model.
Alongside errors, however, are cases where humans involved in safety systems have understood the rules, and have made conscious decisions which have had the effect of violating them.
A common example used to illustrate that is the hypothetical pilot who crashes into a power line while doing a low pass over his girlfriend’s house: Fully aware of the rules and safety implications, but deciding to ignore them.
The sports aviation bodies have been increasingly been all over this in recent years. RAAus now has human factors modules incorporated into its training syllabus well in advance of anything that a CASA pilot will encounter (to the extent that CASA license holders wishing to acquire RAAus credentials are now required to undergo additional training)
In a “just culture,” errors would be addressed through training, enhancements to safety systems, etc; But violations would be punished, because it isn’t “just” to have people running around breaking rules all the time without some kind of regulatory response. Moreover, there are very few safety lessons to be learned from violations that haven’t been learned thousands of times already (“Oh, look, yet another idiot hit a power line and turned himself into a lawn dart.”), so the safety messages arising from them are muted and the punishment is emphasised instead.
It seems to me that in the Pel-Air case, the ATSB has decided that the pilot was aware of rules pertaining to refuelling, oceanic weather, selection of alternates, etc; and chose to proceed anyway.
So in the “just culture” model, that’s a violation, not an error; and ought to be punished, not understood. The fact that the pilot made the decisions he made in the context of his employer’s safety systems (or lack thereof) loses importance.
It seems to me that if this continues, we’ll be on a path towards the bad old days of holding people criminally liable for accidents/incidents. The effect of that on safety is well understood: Liability-conscious individuals will neglect to report incidents, no lessons will be learned from unreported free-kicks, and accident rates will consequently increase.
If the Government is serious about its “just culture” efforts, it needs to apply a bit more maturity and depth to its execution. Reflexively dumping on pilots following multi-causal accidents isn’t going to get us anywhere useful.
ATSB 'leads' air safety into a retreat from Reason? | Plane Talking
Mr Dolan: The mechanism we have arrived at, which seems to work well, is one that looks to identify the shape of issues as early as possible and to get them sufficiently clear so that the relevant party can start proactively doing something about them before the investigation is even complete.
And a selection of Roger Bacon's 'yuck-speak' quotations, 'a series of a million'. (Refer FLIGHT and FLIGHT INTERNATIONAL when the 'Straight and Level' column was in the hands of the brilliant Mike Ramsden.)
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Elephantitis of aviation?
Fantome, I think Mark Lathams "A Conga Line Of Suckholes" would better suit Beaker.
It is unbelievable that Beaker could dribble the below comment:
What a fool. Reason's work does include error and violation. And in the 'world according to Beaker' we have come a long way since Prof Reason. We have? Am I missing something here? Is there another method of analysis, investigation and safety system methodology being used worldwide with proven success that we in Australia aren't privy to?
CASA promulgate Reason's methods, the ATSB investigators follow his methodology, hell even the CASA Accident Branch Liaison Manager or whatever you want to call him lives, breathes and craps the Reason model, yet Politician Beaker who holds career highlights such as postulating, pondering and spinning has found something better? A career bureaucrat who is skilled in bean counting, turd massaging, philosophizing, has a PHD in tautology, and who has taken a once reputable and respected organisation like the ATSB and destroyed it in under 4 years, knows better?
OMG. He has spent to much time with Albaswisscheese and Mrdak the magnificent.
Then you have the Skull. Director of Aviation Safety you say? The guy who refuses and dispells organisational factors and a host of other causal factors as being part of an accidents cause and he goes straight for the Pilots throat as the sole cause? WTF! This guy is living in the 80's still and has no concept of latent conditions, root cause and contributing factors. And he is the head honcho of Aviation Safety in Australia? What about his belief in Human Factors? You know John, looking at things holistically?
Then you have his Associate Director who doesn't even believe in the Just Culture methodology, yet a Just Culture is promulgated by his beloved ICAO and therefore passed down to the 'state' which he is part of. WTF?
These people have lost the plot. They are disconnected from the aviation mainstream. They have their noses buried in troughs and their fingers buried in spreadsheets. They are supported by an inept and equally out of touch Minister who is part of a Government that consists of dross.
Final note:
I have chosen to tone down my 'colourfulness' and desisted from posting any pictures in this posting, just for something different! Not sure if I like it, but I thought it would be interesting. Regardless, you cannot deny the facts that either a royal commision or a complete dismantling of the current aviation portfolio's is absolutely required.
Selah
It is unbelievable that Beaker could dribble the below comment:
If we want to go to Professor Reason’s model of investigation—though we think we have come a long way since Professor Reason’s initial work in the 1990s—there is error and there is violation.
What a fool. Reason's work does include error and violation. And in the 'world according to Beaker' we have come a long way since Prof Reason. We have? Am I missing something here? Is there another method of analysis, investigation and safety system methodology being used worldwide with proven success that we in Australia aren't privy to?
CASA promulgate Reason's methods, the ATSB investigators follow his methodology, hell even the CASA Accident Branch Liaison Manager or whatever you want to call him lives, breathes and craps the Reason model, yet Politician Beaker who holds career highlights such as postulating, pondering and spinning has found something better? A career bureaucrat who is skilled in bean counting, turd massaging, philosophizing, has a PHD in tautology, and who has taken a once reputable and respected organisation like the ATSB and destroyed it in under 4 years, knows better?
OMG. He has spent to much time with Albaswisscheese and Mrdak the magnificent.
Then you have the Skull. Director of Aviation Safety you say? The guy who refuses and dispells organisational factors and a host of other causal factors as being part of an accidents cause and he goes straight for the Pilots throat as the sole cause? WTF! This guy is living in the 80's still and has no concept of latent conditions, root cause and contributing factors. And he is the head honcho of Aviation Safety in Australia? What about his belief in Human Factors? You know John, looking at things holistically?
Then you have his Associate Director who doesn't even believe in the Just Culture methodology, yet a Just Culture is promulgated by his beloved ICAO and therefore passed down to the 'state' which he is part of. WTF?
These people have lost the plot. They are disconnected from the aviation mainstream. They have their noses buried in troughs and their fingers buried in spreadsheets. They are supported by an inept and equally out of touch Minister who is part of a Government that consists of dross.
Final note:
I have chosen to tone down my 'colourfulness' and desisted from posting any pictures in this posting, just for something different! Not sure if I like it, but I thought it would be interesting. Regardless, you cannot deny the facts that either a royal commision or a complete dismantling of the current aviation portfolio's is absolutely required.
Selah
Last edited by gobbledock; 26th Nov 2012 at 09:29.