I agree absolutely with Robert's opinion; Reading in Aviation Safety Digest (the old style with all the accident/incident reports) about Cause of Accident: 1. Pilot Error (choosing wrong paddock for forced landing etc ). 2. leaking fuel line. 3. Faulty Fuel gauge used to really bug me. Hindsight is always perfect and judging the pilot's actions after the event is very unhelpful as per Robert's reasons.
I also agree we need a non-judgmental narrative report of each and every glider accident and serious incident in Soaring Australia and on the GFA web site.
PeterS
----- Original Message ----- From: "Robert Hart" <[EMAIL PROTECTED]>
To: "Soaring in Australia." <[email protected]>
Sent: Thursday, April 21, 2005 10:02 PM
Subject: RE: [Aus-soaring] Re: Accident Investigation Reports
On Thu, 2005-04-21 at 20:24 +1000, Christopher H Thorpe wrote:The use of the term "system failure" is interesting but it is not clear in what context it is being used.
Please note that I am not a safety management expert - so my understanding of modern safety management practice may be faulty...but this is how I understand things...
Modern safety management regards all accidents as a failure of the system - which is everything involved in the accident from the pilot's basic training through to a less than perfect maintenance job etc. The old usage of 'pilot error' to ascribe fault for an accident to a pilot's poor judgement is not seen as useful as this masks the wider (system) issues that led the pilot to make that poor decision. It also very much ascribes 'blame' which is seen as a major reason that incidents are not reported by pilots.
I am sure you are aware of the accident 'pyramid': for one fatal incident, there are quite a few serious injury incidents, many minor injury incidents and heaps of 'near misses'. Only by reducing accidents at all levels are we going to reduce the fatalities.
We thus need to encourage reporting - and this means we need a no fault system.
What is clear is that the majority of accidents are caused by deficiencies with pilot skills and judgement. And many accidents result from a series of factors that may include external influences (e.g. physiological). Even the news report of this latest accident indicates there may be a sequence of events leading up to the accident (overshot runway? Stall/spin?). However, we should not speculate.
According to my understanding of modern practice, ascribing accidents to pilot error is missing the point. Why did they make that decision and what does that tell us about the system in which they were operating?
I reviewed the GFAs business plan and the only ongoing action regarding accident investigation relates to having the ATSB provide a level of accident investigation for gliding. At this time the ATSB will not investigate gliding accidents. However, the ATSB does monitor gliding accidents and they review all accident reports to identify safety deficiencies. If a deficiency is identified, the ATSB will make recommendations to the GFA and others (regulatory authorities, operators, manufacturers or other agencies). For example:- http://www.atsb.gov.au/aviation/rec/rec_detail.cfm?ID=9 or http://www.atsb.gov.au/aviation/rec/rec_detail.cfm?ID=236
Such a review of accident/incident reports is also part of the GFA Business Plan to ensure appropriate safety standards are developed and. Recent examples of this have seen the introduction of lookout notes in response to recent mid-air collisions. Such analysis and dissemination of information is far better than merely making every accident report available to all and sundry.
I am afraid that I would have to disagree with this. This implies that the ordinary glider pilot has not ability to read and understand the report and must be told, from on high as it were, to operate in a particular way without needing to understand the why. If there are detailed accident reports, they should be made available to all pilots. The GFA has a web site that is well suited to such a purpose.
As for the summary report in Soaring Australia, with the exception of the reported fatal accident, which was still under investigation at the time, it is not too difficult for an experienced person to understand how a type of accident occurs and what remedial action is needed. And none are "new" accidents (numerous heavy landings, hitting a fence, ground loop, wire entanglement) and the lessons are already known.
That many of these accidents are not new and yet are still occurring would suggest that the system is failing somewhere. Should we just accept these - and by this acceptance also accept that we will kill glider pilots with some regularity?
-- Robert Hart [EMAIL PROTECTED] +61 (0)438 385 533 Brisbane, Australia http://www.hart.wattle.id.au
_______________________________________________ Aus-soaring mailing list [email protected] To check or change subscription details, visit: http://lists.internode.on.net/mailman/listinfo/aus-soaring
_______________________________________________ Aus-soaring mailing list [email protected] To check or change subscription details, visit: http://lists.internode.on.net/mailman/listinfo/aus-soaring
