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I have read with interest the ongoing debate on GFA safety. I think the debate keeps losing the thread that we need an awareness of incident causation, reporting and investigation, and analysis, and it is not limited to investigation of accidents. An incident system is a very necessary part of safety management. The reason we have incident reporting and investigation is for getting information on what can we be doing to improve performance, (granted we know many of the standard causes). The purposes of incident reporting and investigation are for enhanced communication of the risks, to ensure the incidents don�t recur, and to improve overall performance. Root causes relate to issues such as training, communication, systems, audits and review, human factors etc. Examples of some questions we could ask along the system improvement approach as a result of investigations (of incidents, not just accidents) may be:
Are we training our instructors adequately? Is there enough followup on instructor standards?
Is the annual check system adequate?
Have we seen an increase in a particular sort of incident/accident that may lead us to believe some area of our training or system is now not working effectively?
Do we have a consistent training standard across the states?
Is club site check system working?
Are there enough resources going in the right areas?
Are we communicating airworthiness and operations issues well enough?
Do we have enough awareness in our membership in these core risk areas?
Are our competition safety standards good enough?
How well are we implementing safety measures?
What human factors are significant contributors to gliding?
To get to these sorts of questions, you need more information than what you will gain from the straight accident data. The publishing of root causes of incidents (and analysis) if done correctly identifies and communicates the system issues and risks. If we have no trained people for investigation, this is a deficiency in our training which needs addressing and is not a reason for not doing this. If we need to clarify or indemnify the investigators, this avenue should be explored. To sit back and claim liability issues prevent us learning is a very narrow approach. Our MOSP directs instructor panels to investigate accidents (without training) so what separates the instructors panels from the GFA representatives who investigate? At the very least, instructors should know about incident causation models so we better find system root causes, rather than direct causes.
If we are not collecting the near miss events, and checking and reviewing systems effectiveness, the safety performance of the sport is likely to decline. Bob Hall informs me that �We have had for many years what is meant to be a simple confidential system of accident and incident reporting with an appropriate form designed to collect the appropriate information. This is available from the office.� How many people would be aware of this? What data have we gleaned from this? Is it being used? If not why not?
In this whole debate, we should be looking to improve performance. To quote the sumup of a royal commission in the UK on a major safety accident some years back � �Continuous good news, you should worry�.
Jenny Thompson | 
