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Hi Fellow Pilots
Have I missed something in this exhaustive debate?
Airline pilots and other pilots generate detailed reports of their
accidents/incidents. These are widely circulated. I have always assumed they did
this to help others learn from their mistakes/errors of judgement, etc. So why
are glider pilots different?
My motto: Learn from others mistakes, you will not
live long enough to make them all yourself. This presupposes we can find out
about others mistakes!
Cheers
Michael
----- Original Message -----
Sent: Monday, November 07, 2005 11:01
PM
Subject: RE: [Aus-soaring] ACCIDENT &
INCIDENT REPORTING
Mark
Thanks for your
reply.
Below is a response and I have
included my further points in yours in caps below.
BUT .......... (a) How about you
play the ball and not the man. Argue your case by all means but don't demand
to win and don't attack the contributor because they continue to argue
theirs.
(b) It is interesting that my Poll
on The Gliding Forum was 21 votes from people who think that Incident and
Accident Reports are useful and 2 that don't. 91.3% in favour and given that 1
of the nay-sayers might have been you voting twice, I reckon that's strong
support for the concept ......... but then what do I know in my
vacuum?
You and the other no-voters can
have a meeting in a phonebox somewhere.
I apologise to the other readers
but Mark has demanded a response to each of his points.
See other comments below in
CAPS
Regards Geoff
----- Original Message -----
Sent: Monday, November 07, 2005 12:56
PM
Subject: Re: [Aus-soaring] ACCIDENT
& INCIDENT REPORTING
Geoff Kidd wrote:
> I suggest that the main
question for the GFA Board and the Management is
> something like
"What is in the best way to build a safety conscious culture
> in the
interests of all of our members" and I say that regular factual
>
reporting is a good way to do that.
See, this is the problem with
having discussions like this on mailing lists.
Mailing lists tend to
favour people who argue their point of view in a
vacuum, without
considering any counterpoints. THAT'S THE KETTLE CALLING THE POT BELLY
BLACK
I've already described a couple of reasons why "regular factual
reporting"
of the kind you've proposed is bad. To
whit:
- It discourages people who are "sensitive" about
humiliation from
reporting accidents/incidents
in the first place;. THIS IS NOT RELEVANT AS I THINK THAT THE CTOO SAID THAT
THEY CAN BE ANONYMOUS IF NECESSARY.
- It relies on
people getting hurt or killed to get its point across. WRONG. I AM NOT
ARGUING THAT ONLY INJURIES OR FATALITIES ARE REPORTED TO MEMBERS. SOME
MAY BE THOSE TYPES OF OCCURANCES, AND SO BE IT, BUT I ARGUE THAT
ALL ACCIDENTS AND INCIDENTS SHOULD BE REPORTED TO
MEMBERS.
- It adds responsibility for extra workload to
people who are volunteering
their time, and who
probably don't appreciate having their spare
time
eaten up on the insistence of other people
who aren't volunteering theirs. THAT WOULD BE VALID IF IT WAS FACTUAL. THE
CTOO ADVISED THE WAGGA SAFETY SEMINAR THAT THE DATA EXISTS, IT JUST ISN'T
REPORTED TO MEMBERS, AT THE DIRECTION OF THE BOARD. THE CTOO FURTHER
SUGGESTED THAT I WRITE TO THE BOARD TO ARGUE MY CASE. I HAVE ALSO
VOLUNTEERED TO DO THE TYPING AND COMPOSITION DONKEYWORK FOR THEM TO EDIT IN
ANY WAY THEY WISH ............ AND BEFORE YOU ACUSE ME OF WANTING TO
INFLUENCE THE OUTCOMES, I HAVE NO DESIRE, NOR DO I HAVE THE EXPERIENCE TO
MAKE A FACTUAL OR EVALUATION JUDGEMENT, BUT I CAN DRAFT THE WORDS
AND PREPARE THE ELECTRONIC DOCUMENT FOR THEM TO USE AS A BASIS FOR A
MONTHLY EDIT.
- It doesn't provide any deeper
insight into safety than could be achieved
by
writing about precisely the same issues without having to wait for
an
accident to occur. I THINK YOU ARE DEAD
WRONG ON THIS. THEORY MIGHT TURN YOU ON, BUT I CONTEND THAT REAL INCIDENTS
ENCOURAGE THE READER TO ASK SOMETHING LIKE ................ WHAT WOULD
I HAVE DONE IN THAT INSTANCE AND WHY WILL I NOT GET SUCKED INTO THAT ERROR
SOME TIME IN THE FUTURE. AS AN EXAMPLE, WHY DOES THE CTOO GO TO SO MUCH
TROUBLE TO HAVE VIDEO AND SEEYOU EVIDENCE AT THE SAFETY SEMINARS? I THINK
THAT THE REASON IS THAT IT HAS MORE IMPACT AND MUCH MORE MEANING WHEN
ATTENDEES SEE TRUE EXAMPLES.
"In the real world," those counterpoints
would be addressed and incorporated
into any proposal that was finally
delivered. On a mailing list on the
Internet, though, someone like
you is perfectly free to pretend they've
never seen any of those points,
and blithely continue with their original
crusade without making a single
iota of modification to their course.
Seriously, Geoff, we might as well
have never had the discussion, because
it hasn't influenced your
conclusion at all, has it? You certainly haven't
responded to any
of those points in any meaningful way, so as far as I can
see you've
totally ignored them. NOW I KNOW THAT MY ABOVE RESPONSES WILL NOT SATISFY
YOUR NEEDS FOR NON-BLITHE CONTINUANCE BUT SO BE IT.
I think that
attitude is intellectually irresponsible. I'm pretty sure
that the
ops panel will agree with that conclusion and reject your proposal;
and
when they do you'll probably feel disenfrancised just like Robert H
does,
even though the rejection of your proposal will have nothing to do
with
the intransigence of the ops panel and everything to do with the
fact
that the proposal never had legs in the first place because you
refused
to address the significant, serious deficiencies outlined in the
four points
above. MARK. I KNOW I AM JUST A MEMBER .... BUT I DO HAVE A
RIGHT TO PUT A CSE TO THE BOARD AND ARGUE IT AS HARD AS I CAN. THANKS FOR
THE SUGGESTION, BUT I WASN'T PLANNING THE FEEL DISINFRACISED OR ANYTHING
LIKE THAT. I EVEN PLAN NOT TO DUMP ANY BALAST ON YOU IF WE EVER MEET IN THE
AIR.
> It is my contention that it is not correct management to
say that Accident
> and Incident Reporting should not be done because
we are too busy at the
> moment.
You've just erected a straw
man. Nobody has suggested that accident and
incident reporting
shouldn't be done. The argument has been that accident
and incident
*publication* shouldn't be done, because publication is actively
harmful
to the safety management culture you're trying to inspire. IN
ALL OF MY POSTS, WHEN I ARGUE FOR ACCIDENT AND
INCIDENT REPORTING I AM ARGUING FOR THAT REPORTING TO BE TO THE
MEMBERSHIP. I HAVE ALWAYS REALIZED THAT REPORTING WAS DONE
WITHIN THE ORGANIZTION ... GO BACK AND READ MY EARLIER POSTS.
What do
you have to say in response to that? How do you address the
four
points I"ve raised above? Or are you completely ignoring them
and
hoping that the change you want will go through anyway and damn
the
consequences? NO MARK. NOT IGNORING THEM. I JUST THINK YOU ARE WRONG
AND YOUR ARGUMENTS DON'T HAVE MERIT. APART FROM THAT, I THINK WE
HAVE CONCENSUS.
> There appears to be an underlying theme
from some who have posted on this
> thread that they have heard it all
before, all of these lessons are known, so
> why doesn't someone just
write a theoretical article or example about it.
> There are three
points I would like to respond to this:
>
> 1
A real example is much more sobering and forceful than theory.
It
is? Why? If that's true, why has ATSB removed its accident
reports from
Flight Safety Australia? Can you name any other
aviation magazines across
the world which publish accident reports?
Can you name any other aviation
organization anywhere in the world which
doesn't have a formal accident
investigation capability but which
publishes accident reports anyway? THE HGFA, THE AUF/RAA. MY USA CONTACTS
SAY THAT THEIRS IS ALL FAA AND THEIR ,MEMBERS FEEL THAT THE REPORTS ARE
USEFUL.
> 2 As a relatively new pilot involved
in Cross-Country I want to know what
> real world mistakes others have
made and I want to be able to learn from
> those.
As a new
pilot involved in Cross Country, do you believe that you're
incapable of
learning about safety unless your lesson has blood dripping
from it? THAT
IS IMMOTIVE CLAP-TRAP. SEE RESPOSES ABOVE RE LESSONS TO BE LEARNT BY REAL
WORLD EXAMPLE FOR REAL WORLD PEOPLE.
I like to think that my fellow
pilots aren't so stupid that the only
lessons they can learn are the ones
which have killed or injured people.
Maybe you have a different view of
your peers; If so, please tell the
rest of us where you fly so that
we can avoid that part of the country. I HAVE NEVER ARGUED FOR THIS BEING
THE ONLY WAY TO LEARN ... SO WHO IS ERECTING A STRAW-MAN NOW.
>
3 It is clear that there are a number of experienced
Instructors who still
> make fundamental mistakes or allow their
students to make them, and I quote
> the couple of examples that are
used at the Safety Seminar ..... so even if
> those that have heard it
all before (and say that they don't need to hear it
> again) can, by
way of example, fly past a perfectly good runway in the
> circuit to
get low and land short/heavily damage an aircraft, newer members
>
need to know about this example and be aware that they too are likely to
be
> tempted to do the same at some time in their flying ..... and it
obviously
> won't hurt Instructors to hear it again either.
Do
you believe publication of accident reports in the magazine will
solve
that problem? I BELIEVE THAT IT WILL ASSIST. AGAIN I ASK WHY
KEVIN'S SEMINARS ARE SO USEFUL? ITS BECAUSE HE PRESENTS THEM IN A STRUCTURED
WAY USING REAL EXAMPLES. AND THEY HELP. AS WOULD THE SAME THING IN PRINT
EACH MONTH, PARTICULARLY IF IT HAS HIS OBSERVATIONS AND RECEMMENDATIONS AT
THE END OF EACH REPORT (TO THE MEMBERS).
If it doesn't solve that
problem, how will you fix the inevitable decline
in accident reports
caused by the fact that those who are embarrassed about
reporting their
accidents will refuse to do so when they know it's going to
get plastered
all over the magazine? You'll have reduced the efficacy of
the
existing accident/incident reporting system for no good reason, won't you?
YOU SAY NO GOOD REASON. I DISAGREE. YOU SAY THAT MEMBERS WILL STOP
REPORTING. I DISAGREE.
> Re your 2nd last paragraph, having
attended the Safety Seminar in Wagga
> recently, I wonder if the CTOO
really does disagree .... and I say that if it
> is worth travelling
around the country to present those very worthwhile
> Seminars, then
it is certainly worthwhile reinforcing them in the Magazine.
Perhaps
you ought to ask the CTOO about that. He has an email address,
and
he has forthright opinions. He'll tell you exactly what he
thinks
about this if you ask him the question. He just doesn't want
to post
it to a mailing list (largely because dicussions on mailing lists
tend to
be inherently useless for providing any useful real-world benefit
to anyone,
as this one appears to have demonstrated) I DID ASK HIM
............ SEE RESPONSE ABOVE.
> Mark said "Is there -really-
anything new to learn that we don't already know
> .....?" and I say
that the answer is a definite YES. Mark may not have
> anything new
that he needs to learn (how good would that be?), but I reckon
> that
every newer member, and every other member with less than say 20,000
>
gliding hours, can learn a lot from well written real world examples of
where
> his/her peers have made mistakes.
... and are those
self-same pilots so dim that they can't learn from
non-real-world
examples? THOSE SELF-SAME PIOTS ARE NOT DIM AND SHOULD NOT BE KEPT IN THE
DARK. YES THEY CAN AND SHOULD CERTAINLY LEARN FROM THEORETICAL EXAMPLES
......... BUT WILL HAVE A TENDANCY TO SAY "I WOULD NEVER DO THAT". I CONTEND
THAT IT HAS MUCH MORE MEANING WHEN AN EXPERIENCED PILOT HAS MADE THE
ERRORAND I THEN HAVE TO ASK ... "WHY DID HE/SHE DO THAT AND WHY WON'T I IN
THE SAME CIRCUMSTANCES."
Ground them, I say. We don't need
pilots like that cluttering up the airspace
and presenting a risk to the
rest of us. I'M GLAD THAT YOU AREN'T THAT RISK TO THE "REST OF
US".
> Taking the example from the Safety Seminar, if you had
asked the
> Instructor "Do you need a refresher on circuit heights and
procedures" before
> you fly today, I would be sure he would have said
something like "Is there
> -really- anything new to learn that we
don't already know .....?", yet the
> fundamental accident still
happened.
Which means that the accidents *AREN'T* being caused by
lack of knowledge. THERE IS NO ONE ANSWER TO THIS, BUT OVERALL I CONTEND
THAT IT IS NOT LACK OF KNOWLEDGE THAT IS THE PROBLEM. IT IS MAINLY POOR
PRACTICES AND AN EROSION OF STANDARDS THAT GET YOU "SUCKED IN" TO BAD
SITUATION. I ALSO BELIEVE THAT EGO & CONVIDENCE GOES A LONG WAY TO
ENCOURAGING A PILOT TO CHANCE HIS ARM ON SOME OCCASIONS, BUT YOU WOU;DN'T
HAVE A PROBLEM WITH EGO WOULD YOU?
In light of those kinds of
suggestions, I'm having difficulty understanding
why you think
publication of accident reports will make a difference. I HOPE THAT THE
ABOVE GOES SOME WAY TO EXPLAINING IT.
The pilots who have accidents
*ALWAYS* understand how not to have them.
Every pilot has been taught how
to land safely, taught how to avoid spins,
taught how to lock their
canopies, taught how to look-out, etc. THEN WHY DOES THE CTOO FEEL THE NEED
TO UNDERTAKE THE SAFETY SEMINARS
We're not dealing with a problem
which is caused by lack of knowledge,
lack of competence, or lack of
awareness. The causes run deeper than that.
And I think you're
trying to apply an overly simplistic solution to them. ALL i AM ADVOCATING
IS ONE ARM OF THE OVERALL SOLUTION. IT WILL NEVER BE TOTALLY SOLVED
............. BUT IT DOES NOTHING NOT TO MAKE THIS VALUABLE DATA
AVAILABLE.
-
mark
--------------------------------------------------------------------
I
tried an internal
modem,
[EMAIL PROTECTED]
but it hurt when I
walked.
Mark Newton
----- Voice: +61-4-1620-2223 ------------- Fax:
+61-8-82231777
-----
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