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REDUCING THE CHANCES-OF STUFF-UPS

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REDUCING THE CHANCES-OF STUFF-UPS

Old 31st Dec 2017, 19:40
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REDUCING THE CHANCES-OF STUFF-UPS

Someone poignantly posted on the thread about the new year's eve disaster when six died in a seaplane on a branch of the Hawkesbury just north of Sydney, that the thought of wishing anyone a "Happy New Year" to some degree stuck in his throat. Which for me prompted the beginning of a line of thought to do with taking a look back to possibly find a way to reduce the number of careless accidents in the year ahead.


How to inculcate in the novice or in the more experienced who repeatedly "gets away with it again" a revitalised sense of an active awareness of the pitfalls of inattention or the cock-sure and dangerous belief that they have the game scunned?

Ossie Osgood of Arnhem Air Charter saw to it that all new recruits to his company ploughed through and read a list of prescribed books including 'Fate is the Hunter' and 'Sigh for a Merlin' so as to acquire an appreciation of the stand-point of those who had gone before and who had the gift to impart in their writings the various key factors that helped to ensure their repeated survival in the hostile environment in which the business of flying has always functioned. Not just their survival, but their newly discovered ability not to be stupid, but to be realistic in assessing every potential hazard.

Ossie was the mentor supreme. He wanted his pilots to think about those who had stuffed up. He wanted to talk with them about what they thought killed Smithy. Or killed Charles Ulm. And what it was saved men like PG (Bill) Taylor from disaster time and time again. But he could not teach them how to take the calculated risk. He knew, and they soon knew, that you cannot pick away at your quota of coal without doing it essentially on your own at the coalface. If on the other hand, Ossie found that he could not get anywhere with certain individuals (whom he soon realised he had initially misjudged and had acted on an erroneous gut feeling in employing them) he would then in a fatherly way take them aside and use his well tuned powers of persuasion to point the object of his disappointment in another direction to that of being the reincarnation of James Bigglesworth.

In John Gunn's book , 'The Defeat of Distance' , there are early passages that tell how the Queensland and Northern Territory AIr Service emerged out of a combination of business acumen (Fergus McMaster, Ainslie Templeton), operational nous and caution (Hudson Fysh) and sheer gung-ho balls for the adventure (Paul McGuiness).

Ossie lamented the passing of the days of pioneering flight but at the same time knew that the future was one that would be driven and held together by a new breed of men and women more attune to pressing buttons than discovering the roots of their craft. Shiny bums devoid of first hand experience of the real character of the business would be employed sitting at their desks devising new programs of risk management and occupational health and safety. Brave new (inevitable) world!
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Old 31st Dec 2017, 21:29
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Congratulations on a superb New Year Post.
So much to consider in there.
My advice to beginners.
If you're not sure about the situation you're in, you probably shouldn't be there and ALWAYS ALWAYS ALWAYS leave yourself an 'Out' that belongs to you and no-one else.
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Old 31st Dec 2017, 22:34
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thanks for that thumbs up BSD. (any facility for straight thinking as opposed to crooked thinking I owe to the indomitable rational brain of the late dad. Que hombre!)

It is beholden upon all of us who have weathered many a storm,
taken a look over the abyss, encountered horrific employers,
said "there , but for the grace of . . . .", to do our mickle
to share what we can (of a vast combined repository of experience),
with the emerging crop of new boys and girls on the block.

suggestions on ways and means of achieving this?


c'mon Dick - dig deep again . . fund the Dick Smith Airmanship Foundation for the
betterment , advancement, advocacy
and dissemination of all strands of the craft.

put together a primer to be issued to every applicant for a Student Pilot Licence. have another version to accompany the issue of every PPL
and every CPL.

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Old 31st Dec 2017, 23:26
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How to put an "old head" on young shoulders is a continuing issue in general aviation. Most young pilots are willing to learn from those with experience as they appreciate one of the most quoted adages in aviation; "learn from the mistakes of others because you won't live long enough to make them all yourself".

If you learn properly you are going to spend the majority of your flying career on the edge of new experiences. Now, obviously this is a rather broad statement but essentially as you gain experience you will gradually begin to push the envelope of conditions in which you will fly. With experience though there comes an insidious danger; the normalisation of deviance.

No, its not my phrase but was coined by a very insightful woman, Diane Vaughan, who researched the Challenger space shuttle explosion. It is the gradual erosion of standards over time until those standards become dangerous if not fatal. To cut a long description short you can have a standard that is safe and sound but over times elements of that standard will be omitted, mostly due to complacency, creating a new and less safe standard. Over time the same thing happens to that standard and so the process continues until you have a very unsafe standard. If your lucky there is a wake-up call where disaster is narrowly averted. If your not, your dead.

There are some horrifying stories out there of experienced flight crews who have monumentally screwed the pooch through a complete lack of attention to procedures and safety. A large number of them occur in high-end general aviation where owner/pilots have let their standards slide but it can also happen in highly trained crew situations. My introduction to the subject was a story of a RAF pilot who nearly put his Tornado G3 into the ground while trying to work around an undercarriage problem so that they could continue a military exercise.

For a little more on the subject check out this link:

https://en.wikibooks.org/wiki/Profes...on_of_deviance
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Old 31st Dec 2017, 23:49
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well said old bean . .. . .. something here for all concerned to have a serious think about. (forgive the quibble- where is your self-appointed editor when you need a post critiqued?)
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Old 31st Dec 2017, 23:55
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learn from the mistakes of others because you won't live long enough to make them all yourself
Trouble is, remembering all the lessons, it's a virtual cornucopia of ways to err. From witness descriptions of the Hawkesbury accident it seems a repeat of the Perth Mallard.
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Old 1st Jan 2018, 00:33
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In a way I feel like a lot of the Flight Schools now are too "kind" to their Students. So much of what I was shown when I did my Instructor Rating was all about making the Students feel "Safe" and "Comfortable", which to an extent I agreed with, but felt it went too far in that they were isolated from the harsh truths of Aviation and I know a couple of people from that school have lately lost their lives. I don't blame this school but I do blame a culture that seems to have arisen in which we're trying to be "Kind" and "PC" and always toe the line with students lest one become uncomfortable, feel scared or even worse, make a complaint to their University!!

When I first started, first day of ground school, we were all sat down and introduced to our Ground Instructors, whom to our great luck were two of the best Instructors/Pilots/People I have ever met to this day with a variety of experience from both Civil and Military Flying worlds. Our main Ground Instructor got up after these introductions and told us to look to the left and look to the right and that by the time we finished our Aviation Careers the chances were that one of those people would no longer be with us. It shocked us but put what we were about to learn into perspective, it reminded us that what we were learning wasn't just a job and was certainly no game, it could/would save our lives one day.

There was nothing "PC" or "Kind" in those words or that thought, but it was damned sure one of the best things that could have been said to us at the beginning and set us on the right foot.

I've read Fate of the Hunter and a couple of other books like that and could not agree more that they should be required reading material, but feel they won't be as it'll scare too many students.
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Old 1st Jan 2018, 01:01
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I once got a 210 that done a wheels up. The pilot was ask what happened. He said he forgot. The he changed his stroy. We jack the aircraft and selected gear down and down it came.
We had a young lady pilot with us at that time.
I said to her you will never do this.
She said why. I said because ive told you, and you seen what has happened here. She could not understand what i meant. Last year we caught up again after a few yew years. She said thank you. I ask what for, she said the words you gave me on that runway.
Oh i said you got it now. She said yes.
There are no old bold pilots.
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Old 1st Jan 2018, 01:39
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Having spent the best part of half a century in this game called "aviation" I fully endorse what has been said above by you all.

I was lucky to have had 'educators' drum all these home truths into me at the start of (and frequently during) those nearly 50 years.

It is regrettable that the current ATSB should be doing the indepth safety education of todays aviators but does not. The current regulator claims to be a safety authority again, they are not and I don't think they ever will be regarded in that way. Their only role is regulation and they don't do that very well either.

CC
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Old 1st Jan 2018, 12:44
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Who reads crash reports on the type you are flying, not just ATSB ones but from any country, eg., Outer Mongolia or wherever ? Also who has studied systems (eg. prop governors) to the extent that they can name a part and what will happen when it fails, ie., will be able to understand failures not covered by the checklist ?
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Old 1st Jan 2018, 15:43
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they can name a part and what will happen when it fails

The function of the third oil line and how it actually did it's job (within the Rotol prop driven by an RDa7 powering the Fokker F27) that pilots in ground school had to try to grasp, in fact did more than one head in , in it's complexity.

Then again, a very much old-hand Dutch trainer at Fokker's training base at Schiphol once answered a question regarding a specific malfunction. He spread his hands wide, saying -
"Eet will NEVER happen."
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Old 1st Jan 2018, 16:28
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Never eever It helps to be cynically suspicious of anything aviational !
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Old 1st Jan 2018, 20:57
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The Australian military shows its aircrew recruits a movie called "Broken Wings", a compilation of aircraft crashing.
Student pilots should be told that aviation isn't safe but can be made that way by knowledge and discipline then shown the movie. Aviation can be wonderful, exciting, beautiful and immensely satisfying and you can make mistakes but there are some mistakes that will turn around and kill you quickly.
Don't do anything stupid.
Unfortunately the regulator and ATSB aren't doing anything to make aviation safe, they just make it more expensive and difficult and reduce the number of people doing it and the hours they fly.
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Old 1st Jan 2018, 22:50
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A great New Years post indeed.

Experience can’t be bought but there is no shame in asking for help! Seeking advice and learning from others fcuk ups! Honesty is also a strong key, if you have fooked up nothing wrong with talking to your peers about it and learning.

As for PC I’m flying schools I’m well out of reality on that one but it would not surprise me. I remember many years my Grade I instructor giving me some very valuable tough love, another examiner teaching me something that indeed saved me in later years, yes I failed the test but learnt a lot.

Don’t ever be to proud in this game as it can bite you so hard, never judge, but also never be afraid to speak up.

I’ve had many roles over the years and have always been known for not putting up with the ever changing b*ll**** in aviation. I’ve finslly found a place that works for me so life is good.

Here’s to a safer year in aviation!
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Old 2nd Jan 2018, 04:52
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I’ve finally found a place that works for me, so life is good.

are you at liberty Mr GA to expand a little on that?
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Old 2nd Jan 2018, 08:36
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As I see it, GA as an industry, has been destroyed by bureaucracy.
Whilst I applaud Far Cu for starting a most worthwhile discussion, sadly I think there is no avenue to pursue it.
You don’t know what you don’t know. To know is to fully understand and relate understanding with experience.
I think it would be impossible, for a student pilot, to read, understand and comprehend CASA’s act, rules, regulations, advice and consistency - if they had a prerequisite degree in English and law and were given five years to study “aviation law”. An ordinary intelligent person has no hope of “knowing” the rules let alone learning and honing the skills.
It is wrong to assume that the “New Year’s Eve floatplane tragedy has anything to do with knowledge, ability, airmanship or equipment at this stage. It is wrong to presume the pilot, company or aircraft were at fault.
“REDUCING THE CHANCES OF STUFF-UPS” is a poorly worded title to the thread and I hope not intended to imply pilot error! What is more concerning is the implication in the second sentence of the thread starter’s post, in the absence of any evidence as yet. Again, I trust they are poorly chosen words.
I think, none the less, the intention of the thread starter is to genuinely explore ways of effectively improving safety awareness and mitigate incidents and accidents which were horrifically evident in 2017.
The “industry destroyed” is, in my mind the prime reason for our collective problem.
There are no aeroclubs, for likeminded people to associate, discuss and share experiences.
There are no country airports with infrastructure and support.
There are very few flying schools with modern equipment and dedicated instructors.
There is little community support and even less understanding of the contribution GA makes to a modern society.
Fuel is costly and hard to access.
Gates are locked.
CASA have no planes, no active industry knowledgeable pilots, industry commitment or industry respect.
Communications (phone and internet) deplorable at most airfields.
Most instructors are themselves students.
ATO’s are almost non-existent.
………………. and many more.
There are literally no avenues to discuss or learn what you DON’T KNOW. The support structures are gone.
Car Drivers, Truck Drivers, Boatmen, Gliders, Skiers, Parachutists, Horsemen, Footballers, Boxers ad infinitude, engage in pursuits that carry personal risk.
None have been pursued to the point of extinction as have the aviation community.
Unless we can restore what has been undone by CASA and the rest – viz –
List of departments and agencies | australia.gov.au
hang up your headsets and find another occupation / hobby.
[I have been an Industry participant 1962 – 2017 I wish all incumbents well in 2018 and beyond]
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Old 2nd Jan 2018, 09:27
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It is wrong to assume that the “New Year’s Eve floatplane tragedy has anything to do with knowledge, ability, airmanship or equipment at this stage. It is wrong to presume the pilot, company or aircraft were at fault.
“REDUCING THE CHANCES OF STUFF-UPS” is a poorly worded title to the thread and I hope not intended to imply pilot error! What is more concerning is the implication in the second sentence of the thread starter’s post, in the absence of any evidence as yet. Again, I trust they are poorly chosen words.
I think, none the less, the intention of the thread starter is to genuinely explore ways of effectively improving safety awareness and mitigate incidents and accidents which were horrifically evident in 2017.
The last sentence of this quote is absolutely true, and thanks to Captain Casper for pointing out the fact that the title I chose, poorly conveys the aforesaid primary intention. If anyone can suggest a better title I will make the amendment. Also it was never my intention or thought to prejudge any aspect of Sunday's accident. Or to enter into any hypothetical commentary of analysis. (There is enough of that on the thread devoted to that accident.)

The fact that many accident investigations have been seriously flawed, is not the point, simply something to always bear in mind when studying any air accident report. (Incidently, for what it's worth, I too have been "an industry participant" for those same years of service quoted, 1962-2017).

On a broader front, what this undoubtably well informed critic of the industry and the regulator has to say about his take on where it is all heading is depressing in the extreme.

He says - "Unless we can restore what has been undone by CASA and the rest . . .. . . find another occupation." Maybe the time is past, when an effective corrective lobby can be heard and taken seriously. Maybe the rot has truly set in. Throughout the industry the distrust and cynicism is endemic.

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Old 2nd Jan 2018, 12:48
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Reducing the chances of stuff up's? No shortage of information on that subject. Any student pilot and higher can start by reading the complete series of Aviation Safety Digests recently digitised. These are the best sellers (except they are free to read) in the Australian flight safety aviation industry.
https://www.dropbox.com/sh/9wo9qzdor...0LzdqhYva?dl=0
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Old 2nd Jan 2018, 13:40
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It’s encouraging to see such a frank discussion. The comment “to err is human” peaked my attention however. To err is not human and Tony Kern explains why this is so in his book “The Blue Threat” (2009). We are all aware that human factors play a role in aviation accidents. That fact alone should empower every individual to do all they can to overcome our human vulnerabilities. Not to do so is downright irresponsible.
Kern explains that red threats are external to the individual and are considered at an organisational and operational level. Blue threats are the threats that come from ourselves and our team. Individuals should have the curiosity to want to “know what you don’t know”. We need to develop a conscious effort to minimise / eliminate human error patterns. That’s how to overcome the blue threats; complacency, normalisation of deviance etc. That is the foundation from which to build upon with other safety layers of regulatory and company procedures. It’s been a while since I read the book. I can’t hope to do it’s complex analysis justice in just a few sentences. However I hope someone out there will pick it up, along with anything else written by Kern. Consider it, along with any other material you can get your hands on.
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Old 2nd Jan 2018, 17:04
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You have done, I'd say , a lot of us a service, in bringing light to bear on the work of this skilled and prolific writer and researcher. Another of his -

'Flight Discipline
' is the complete tool kit for any aviator, whether military, commercial, or recreational, to develop the discipline essential to becoming a safe and effective flyer. Major Tony Kern analyses the causes of poor flight discipline, gives chilling case studies of the consequences, and lays out a plan for individual improvement. Key words are italicized and review questions included for each chapter. An unequalled guide to this mainspring of good piloting.

First published in the USA in 1998, throughout its 400 pages the author ranges across every conceivable aspect of this subject.

And another from Tony Kern (1997) -

'Redefining Airmanship' offers the first concrete model of the abstract ideal of "airmanship," and gives the reader step-by-step guidance for self-appraisal and improvement in the areas of flight proficiency, teamwork, and good judgment in crisis situations. The author, Major Tony Kern, draws on his extensive flight and crew-training experience in the U.S. Air Force, but his model is invaluable for all pilots, whether military, recreational, or commercial.


"Kern's work is a breakthrough, and a benchmark."
--John J. Nance, author of 'Blind Trust'
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