At 22:38 1/11/2005, Mark Newton wrote:
Ian Patching said he wanted CASA to take a more active role. Well,
that's nice, but they don't want to. They don't even issue incident
report numbers for gliding-related activites anymore.
I feel like I need to point out the elephant in the room here: CASA
doesn't want to play a part. Not interested. Their future is in
regulation and surveillance of commercial aviation: Operations where
innocent members of the public have a likelihood of being hurt or killed
when things go wrong.
That means they'll probably get interested in gliding-related accidents
or incidents involving passengers (non-GFA members), but if everyone
involved is a GFA member they're more than happy to just pass everything
over to the GFA
They've already sensibly reached the conclusion which I think
several people in this mailing list have completely failed to grasp,
which is that we're all in aviation because we want to be, if we hurt
ourselves it's our own stupid fault, so if we don't want to get hurt
we need to keep our own houses in order without expecting the Government
to clean up the mess when we get it wrong.
Secondly, and more directly addressing your comments, Richard: Everyone
in the world has a ready-made source of accident data which they can
use to draw their own conclusions and learn their own lessons about
safety culture in Australia. CASA publishes "Flight Safety Australia"
every couple of months and mails it out to anyone on their list; If
you're not on their list you can get it anyway by visiting
http://www.casa.gov.au/fsa/ and downloading the PDFs.
One you do that, however, you learn something seriously depressing,
which has been covered on this list ad-nauseum in recent years: Pilots
worked out how to kill themselves a century ago, and since then they've
all been making more or less the same mistakes over and over and over
again. The root causes are always the same, the actions which those
causes stimulate are also the same, and the inevitable results remain
disappointingly the same. It doesn't even vary much between aviation
disciplines, which is why FSA (which only occasionally covers gliders)
is useful to us anyway.
That means there's very little benefit in 2005 to spreading around a
few paragraphs worth of report about each and every accident that
occurs. When one does that, the invariable result is that you get
mind-numbing repetition of wheels-ups, low-level accidental spins,
poor decision-making while close to the ground, overload-related
brain failure at critical moments, inadequate situational awareness,
poor look-out, sloppy adherence to procedures despite adequate
training in how to apply them, and inadequate planning.
We see that in Soaring Australia every month, in the HGFA accident
reports. "Oh, look, someone else has been dumped when they went
over the back of the ridge. And look, yet another person has been
upset by turbulent thermic air in weak conditions on a ridge. Oh,
here's one we haven't seen for two or three months, another low air-
time pilot has launched in conditions beyond his experience level,
ballooned immediately after launch, stalled, and broken his leg."
I'm pretty sure that HGFA are really just going through the motions
by publishing their list every month, because very little is really
learned by readers of those reports (reports which might as well
have been produced by a robot with half a dozen buttons which can be
pressed to churn out accident reports from a handful of predefined
templates).
What -is- changing, and the thing we -can- learn from, is techniques
to manage risk and complexity to cut-down on those cookie-cutter
style accident reports. The Reason Model in the 1980's was revolutionary,
and has completely changed aviation safety management. And that
management evolves over time as the holistic picture is supplemented
by new information (even though the new information, in isolation on
a pro-forma accident report, is pretty useless as a learning tool).
The GFA is actually pretty good at that: Anyone who has been to the
safety seminar roadshows over the last half-dozen years should find it
pretty obvious that there's a lot of analysis going on inside the GFA
and in cooperation with other aviation bodies to work out root causes
and provide an awareness of what they are and the techniques to overcome
them. The notes about pilot overload which were stressed this year
are a good example of that.
I think there are individuals on this mailing list (and, for that
matter, throughout the gliding movement) who clamour for detailed,
regular, published accident reports for no reason other than the
fact that it's common knowledge that we can learn useful stuff from
reports in that format. But where did the "common knowledge" come from?
Have a think about it: Is there -really- anything new to learn that
we don't already know from a report that says someone had an
accidental spin and killed themselves? Or that they can't quite
remember why because they went into shock and rationalized the
causes after the event when they'd had time to think about it, but
they happened to slam their glider into a landing hard enough to bash
both wheels into the fuselage? What are you people really hoping to
get out of it?
And before someone challenges me to say why I'm so opposed to the
release of such data: Actually I'm not. I couldn't care less. If
the GFA wants to release such data, I won't object. But
there's a deep-seated strain of misunderstanding about accident
investigation running through some of the people who care about it
strongly enough to keep bringing it up all the time, and I feel
compelled to get some kind of explanation out of those people to
say why they think publication is so important.
Because everyone reading this knows, *KNOWS*, that even if Soaring
Australia and GFA's web site happened to be chock-full of accident
reports, people would still land heavily, still take-off without
canopies, still spin-in from 250' because they've climbed too steeply
on winch launches, still collide with each other, and still come
into heavy contact with bits of geography in ways that are strongly
suggestive of the possibility that they forgot about circuit planning
during an outlanding and instead opted to drag their wingtip through
a fence during a hasty turn onto a last-minute final approach into
the only paddock they could see at the time.
We can already predict each year's accidents which such annoying
precision that we can more or less write the reports before the
accidents happen, so what is there to gain from publishing them?
What are you going to -do- with the data when you have it? How are
you going to improve things? Or is clamouring for accident data the
aviation equivalent of gawking at road accidents as the traffic slowly
parades past, feeling good about the fact that it isn't you?
- mark
Thanks Mark
Apart from your opening comment, it's pretty well right on the
button. And the error is not really relevant to the argument - but
CASA isn't the elephant: it is ATSB that has the primary role (used
to be the only role until April 2004) in accident
investigation. CASA has always - well, for the past 22 years at
least - since CASA was responsible for funding, paid the GFA and its
peers to analyse the RESULTS of accident investigations to determine
whether the standards were adequate. And while some in the GFA would
like to have an independent investigator, that depends very much on
the public-interest value of the safety lessons to be learned. We
have some very committed people in the CASA Sport Aviation section,
and our terms of reference are effectively to work through the
administering organisations - because we are tasked with general
oversight of the GFA's administration of RULES and STANDARDS as well
as assisting with SAFETY PROMOTION.
As Mark says, we are in this game because we want to be, and are
willing to take our own responsibility for doing so. That also means
taking responsibility for our own accident prevention strategies -
hence the GFA Safety Seminars etc. I for one would love to see MORE
safety promotion items in the magazine, but unfortunately my
employment currently gets in the way of me writing them more than it
does to other people.
However, expect to see things on the topic of "Threat and Error
Management" in the next 12 months, and I hope to be able to
contribute to this in the future. Like many other things, the Reason
model is not static as Prof James Reason and others are developing
and refining it.
In part we have to learn that errors are human, and we must build
defences against them. One of those defences is constant vigilance,
and unfortunately a human trait is to relax that vigilance when there
have been fewer accidents, even if the reason for this is statistical
rather than better protection mechanisms. Because the errors are
part of our human nature, unless there is gross (even criminal)
negligence immediately leading up to an incident or accident, NO
BLAME should attache to the unfortunate person involved. Heaven
forbid that we should see a spate of accidents in gliding due to
neglect and lack of respect for the established rules (written in
blood, as is most safety legislation), but we must be wary and there
seems to be a trend in aviation for this kind of accident to be on
the increase. Time for the watchdogs to start barking about these
issues, but a reversion to pre-1980s style allocation of "cause" to
every incident will not do any of us any good - rather we ALL need to
recognise and exercise our mutual obligations for safety in our
chosen recreation.
Wombat
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