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It would appear that the same mistakes still seem
to happen,even when they do get reported. Same dog different bark.It would seem
that some are destined to make all the mistakes, some will learn from them,
while others are just born brilliant. Regards to all I
know...JR
----- Original Message -----
Sent: Tuesday, November 08, 2005 9:23
AM
Subject: Re: [Aus-soaring] ACCIDENT &
INCIDENT REPORTING
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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