Robert Hart wrote:- "We thus need to encourage reporting - and this means we need a no fault system."
"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?" "...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." "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?" ________________________________________________________________ The reporting of accidents and incidents is mandatory (Transport Safety Investigation Act - Sections 18(1) and 19(1) refer). The objective of investigating accidents and incidents is to prevent the occurrence of future accidents and not for the purposes of apportioning blame or liability. Legal causality will be determined by the Courts. The unfortunate fact is the majority of gliding accidents occur due to judgement and skill errors. Whether you categorise this as "pilot error" or "system failure" doesn't negate this. It is correct that there are usually several causal factors leading up to an accident (a chain of events if you like), but in many cases they still involve a sequence of judgement and skill errors. The key to accident prevention is for the pilot to recognise the initial mistake and break the chain of events while it is still safe to do so. But this is not easy and requires the pilot to have good proficiency to begin with; in other words, pilots need to be proficient in everything from aircraft handling, regulations, airspace, to understanding weather. As someone from the Soaring Society of America once wrote, "pilot proficiency relates to the pilot's ability to perform tasks associated with the safe conduct of a flight with 'expert correctness'". Such a level of proficiency is difficult to achieve in gliding, mainly because it is a part-time activity. Nevertheless, this shouldn't prevent us from trying to improve our proficiency. In addition, human beings are not infallible and are prone to making mistakes. Derek Piggot once wrote that much of our flying becomes semi-automatic and, unless we make a conscious effort to check what we are doing, things can go seriously wrong. Also, a lack of fitness can be a contributing factor. We know these things yet people still fly when unfit (headcold, tired, etc.), or under stress, or without adequate food/water/etc. Some pilots have also been known to "push the margins" even when they know they shouldn't. Why do pilots make the decisions they do? Usually because in their judgement it is correct or that they think they can get away with it. All the training and reinforcement possible will not prevent mistakes being made or the deliberate flaunting of rules. However, this doesn't mean we should just accept the current accident rate. To quote the late Mike Valentine, a basic principle in safety management is "systematic attacks on accidents pay dividends". It will only be through proper training that the risk of accidents caused by judgement and skill deficits will be reduced. In my opinion this is where the GFA Flight Safety Seminars have added great value. I also don't believe the current system of disseminating information gleaned from reports implies that glider pilots do not have the ability to read and understand the reports. The system works best when those with the expertise in the field bring identified deficiencies to attention and introduce or develop appropriate safety standards. Even the ATSB does not make all reports available as they only conduct in-depth investigations when it is considered likely to enhance aviation safety. The ATSB also has a comprehensive regime of protection for sensitive safety information provided for in the Transport Safety Investigation Act to support the principle that such information is to be used for safety purposes only. I doubt the GFA would be offered the same protection for its reports. If you really want to read glider accident reports to learn what mistakes pilots are making, the NTSB has a very good selection (go to http://www.soaringsafety.org/prevention/ntsb.html). _______________________________________________ Aus-soaring mailing list [email protected] To check or change subscription details, visit: http://lists.internode.on.net/mailman/listinfo/aus-soaring
