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-   -   State of Safety Culture (https://www.pprune.org/pacific-general-aviation-questions/607180-state-safety-culture.html)

josephfeatherweight 29th Mar 2018 21:19

State of Safety Culture
 
I think it is a damning indictment on the state of our safety culture in this country that a thread about an aircraft (carrying passengers) that appears to have run out of fuel and made a forced landing on a highway, is locked from further discussion. Further, I think the fact that our, so-called, regulator hasn't made a comment about it, further paints the picture of the safety reporting in our industry.
What does a fresh CPL make of this sort of behaviour - do they "cover up" a mistake - "Hey, airlines do it, CASA appears to do it, the ATSB takes so long to talk about it that it doesn't matter any more - I won't mention it." With that sort of attitude, it won't be long until someone keeps "hiding" things until they run out of fuel!
Mistakes happen - sometimes big mistakes - it takes leadership and professionalism from ALL involved (pilot, company, regulator) to step up and say - "This happened, we are looking into all the reasons this happened and will strive to ensure it doesn't happen again."
Man the F%CK up...
PS - I am aware that the individual pilot in this case has probably been directed to keep his mouth shut - I'm talking more generally about people speaking up about their errors...

megan 30th Mar 2018 00:39

It is a pity the event is clouded in such secrecy, there is talk on the streets that it was the result of fire warnings on both engines, not improbable, but who knows. Might explain both engines being feathered. I say not improbable because on one four engine type in the past feathering an engine could result in all four feathering.

Centaurus 30th Mar 2018 01:27


I say not improbable because on one four engine type in the past feathering an engine could result in all four feathering.
Definitely happened during WW2 and several Lancasters went in. I personally had it happen in a Lincoln but fortunately on the ground.

LeadSled 30th Mar 2018 03:08

Joseph,
I am afraid the "Crime and Punishment" approach that underpins everything aviation in Australia just promotes hiding things. Why would it be otherwise??

The so called CASA "Just Culture" really means the "Just" culture, "Just get the bastard".

The way the system works, in practice, is to only encourage non-reporting, a system that is not really interested in what produces the best air safety outcomes, only "compliance and enforcement", said "compliance and enforcement" based on a highly variable interpretation, by multiple individuals, of our internationally acknowledged complex, convoluted and contradictory regulation --- which are world leading by weight of word or page count, but otherwise a complete failure at achieving the best possible air safety outcomes.

The amazing thing is the resilience of what has become know as the "iron ring".

There have been more Royal Commissions, Parliamentary inquiries, and other forms of investigation, into the formation of and administration of air law in Australia, than any other Commonwealth department or instrumentality, all to no avail. Including the longest inquiry since Federation, Morris.

Those of us who have been around a while know the commercial damage that has been done, as "aviation" has languished compared with other Australian industry, or the aviation sectors of comparable countries.

In an economy that has had unprecedented growth since the Hawke/Keating era, aviation has significantly contracted, because it simply cannot cope, let alone prosper, under such a regressive and punitive set of administrative (not really "safety" at all) laws.

Quite apart from the more obvious, former export industries have been destroyed in the MRO sector, those that survive, only survive because they have EASA/FAA/ other OS approvals, rendering CASA irrelevant.

No industry could cope and prosper under the regime of ultra micro-management that is visited on the aviation community by such a both aggressive and regressive "public service" bureaucracy.

And, it not as if you can say: "Well, at least we have the world's safety aviation", because we simply do not.

As a result, it is quite predictable, in theory and practice, that the Australian approach cannot produce the best air safety outcomes.

We fall far short of the US in all recognized categories of air safety outcomes, but CASA, the politicians, the bureaucracy, and sadly too much of the aviation community, is willfully blind to the real situation.

Tootle pip!!

Car RAMROD 30th Mar 2018 03:23


Originally Posted by megan (Post 10101642)
It is a pity the event is clouded in such secrecy, there is talk on the streets that it was the result of fire warnings on both engines, not improbable, but who knows. Might explain both engines being feathered. I say not improbable because on one four engine type in the past feathering an engine could result in all four feathering.


Wondering if you know, because I don't, does the Conquest use photo-electric detectors?
Early king airs did, you'd apparently get a fire warning because of light getting in on them, but just keep the turn going and see if they go out before doing anything like shutting an engine down. Fortunately for me I never had that happen as mine didn't have photo-electric detectors.


But back to the main topic- yes I agree that there is a reluctance by many to report. Not necessarily just to CASA/AvMed/ATSB but also to an employer. Part of it can stem from ones early days in GA where the boss would say "if you write on the MR I will sack you."
Changing the overall attitude would be very difficult to achieve.

Jeffory 30th Mar 2018 03:35

The safety culture in GA is non-existent, speak up and the next guy waiting in line will take your job. No pilot is allowed to get in the way of revenue.

YPJT 30th Mar 2018 04:25

On face value it would appear This outfit were not keen to have their incident widely publicised either.

megan 30th Mar 2018 04:35


does the Conquest use photo-electric detectors
No, has a pair of wire loops.

CASA, the politicians, the bureaucracy, and sadly too much of the aviation community, is willfully blind to the real situation
The ATSB get a miss there by name, but guess come under the bureaucracy tag. Putting in a report to them is a luck of the draw as to whether they might be interested. You would think an engine failure departing an oil rig at the most critical point in the profile would raise their interest. Not a bit of it, didn't contact either of the crew for follow up, nor does the event appear in their publicly available records.

Then we have Norfolk, less said the better. :{

No pilot is allowed to get in the way of revenue
Yes you can if you have balls, in this particular case the individual has no balls, if you get my drift. Was customary for operations to try and overload flights, some pilots bent to their will thinking as your post hints, but a pilot with no balls used to tell them where to go, also stood their ground on duty time when flying singles and had to front the owner, don't you want to fly twins was the question put. Earned an enviable reputation with the owners as a result. Some of the pressure is self inflicted, though there are company's who will push and push of course.

tuck 30th Mar 2018 05:14

Same engine different type
 
Had a situation a very long time ago with the same engines. Driving rain, go around from minima both engines indicated fire. So dug into my pockets for a coin to toss, remembered I was in GA and therefore no lose change. Carried on to alternate. Fire indications came and went at the same time, lasted maybe 15 seconds. And no I didn't bury them into the red, just a nice gentle power application to go-around power.

Lookleft 30th Mar 2018 05:59


On face value it would appear This outfit were not keen to have their incident widely publicised either.
I wonder how long they will appear on the Qantas safety video?

Lead Balloon 30th Mar 2018 07:45

I’ve asked the rhetorical question in other threads: What pilot or operator in his, her or its right mind would volunteer information about an incident to ATSB or CASA, given their behaviour?

[T]here is talk on the streets that it was the result of fire warnings on both engines, not improbable, but who knows. Might explain both engines being feathered. I say not improbable because on one four engine type in the past feathering an engine could result in all four feathering.
In that event there’d be defects entered in the maintenance records for the aircraft, then clearing endorsements by qualified engineers, and the whole fascinating story could be told now. Just a weird quirk of flying machinery that resulted in a prudent decision by the crew, under pressure, to make a forced landing that resulted in zero injuries or damage, with expert engineers confirming no defects soon afterwards, followed by a safe and happy flight for all concerned to the original destination.

FGD135 30th Mar 2018 09:54

Moderators,

Why was that thread locked? Thousands of other similar threads are allowed to go on forever, but that one had to be locked.

Are you forgetting what the "R" in PPRUNE stands for?

Ex FSO GRIFFO 30th Mar 2018 10:53

Well, here's a 'd h' question from a person who knows bugger-all about 'hot air balloons'....."

Post #7 link....

"The balloon had 24 passengers in the basket when it crashed."

Wot's the max number of bodies for a 'hot air balloon'...?

How is this number 'calculated'... ? Are the punters weighed?

Is it a function of weight vs size (volumetric capacity of Balloon)?
Most 'reasonable' assumption....

Is it a function of 'How big is the basket'?
Shades of our infamous C-209......

Is it a function of how many 'bods' turn up for the gig..?
Sounds like some previous operators I have known....who have been known to fly the aforementioned '209'.......

Curious is all......

Cheers :hmm:

Thread drift Oi know....but.....I wanna know.....

tail wheel 31st Mar 2018 04:38

The thread ran it's race and had degenerated into a circuitous round of re-quotes and meaningless and inflammatory comments.

Go back and read the posts for page 7 and 8, including numerous quotes and conjecture.

The relevant point is the known facts dried up several pages before the thread was closed and all beyond that point added nothing to the thread.


Are you forgetting what the "R" in PPRuNe stands for?
Rumour:
noun
a currently circulating story or report of uncertain or doubtful truth.

verb
be circulated as an unverified account.

Rumours generally have their origin in reasonable, logical but unconfirmed facts, generally of a second hand nature. Many of the posts on the last two pages fail that test. Indeed, posts 146 and 156 confirms my opinion.

When new facts and evidence becomes available, feel free to commence a new thread.

Lead Balloon 26th Apr 2018 01:00

And still no details of what really happened?

Buswinker 26th Apr 2018 02:13


Originally Posted by Lead Balloon (Post 10130296)
And still no details of what really happened?

rumour has it pilot has found alternative employment

Bend alot 26th Apr 2018 02:18

An ATSB spokesman said "during descent into Broome airport, the right then left engines began to surge. The pilot shut down the right engine and made a mayday call. Shortly after, the left engine failed and the pilot conducted a forced landing on the Great Northern Highway,”.

Very interesting that a false fire warning indication gives engine surges - that's hardly a quick maintenance fix!

FGD135 26th Apr 2018 07:07

Fuel exhaustion
 
The Conquest ran out of fuel.

I have an acquaintance in Perth that is well connected to Skippers Engineering.

The pilot is no longer employed at Skippers.

Bend alot 26th Apr 2018 08:07


Originally Posted by FGD135 (Post 10130436)
The Conquest ran out of fuel.

I have an acquaintance in Perth that is well connected to Skippers Engineering.

The pilot is no longer employed at Skippers.

I'm pretty sure I checked the ATSB site today and they are still gathering information on this, can you please fwd your acquaintance details on to ATSB so they can learn how to be efficient and learn where to get information.

josephfeatherweight 26th Apr 2018 09:04


The Conquest ran out of fuel.
Shock! Horror!


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