With the advent of FLARM and with it's datarecorder capability, all flights
will be recorded in the future.  I am sure there is software that could be
developed where in a program like SeeYou, it will tell the supervising (L2)
instructor that the pilot has dropped below say 800' above ground level and
has not landed.  This would be flagged and the pilot asked to please
explain.

This sounds like a big brother suggestion but may save lives and prevent
accidents.

PeterS
----- Original Message ----- 
From: J&J Thompson
To: [email protected]
Sent: Wednesday, December 21, 2005 3:17 PM
Subject: [Aus-soaring] accident investigation


 I warily tread into the incident investigation debate.

Firstly, with regard to the fatality at Dalby, the report on our
investigation is available on our website under the 'safety centre' area.
The password protection on it was not supposed to be on it, and has now been
removed so we are happy for people to read it.  We did a very thorough
investigation, and worked with the police, who, in reality didn't have a
clue on where to start.  They were only intested in ruling out foul play,
suicide and illegal activities.  We provided our investigation to the
police, who used it to submit to the coroner.  We have since been informed
in the last few weeks that the coroner will not investigate the accident,
based on the throrough investigation we provided.  Our investigation as well
as the police investigation is available under freedom of information
legislation.

By investigating the accident within days of the accident, we were able to
get all the information promptly while information was fresh.  I doubt we
could do a thorough investigation now, some 6 months after the accident.
Based on our discussions with the police, I hate to think what their
unknowledgable investigation would have looked like.  Words like "fell out
of the sky from 5000ft" was the tone of it.  In our club, we are lucky that
we have some skills, training and experience in accident investigation which
enabled us to have confidence in the investigation and the reporting.

Not conducting an investigation, and hiding behind a police and coroner's
enquiry, will not make you immune to a legal prosection, because if a party
is determined to sue, they will.

Secondly, and more generally, in my work life I have occasion to
train/educate on safety legislation and managing safety.  The point about
the legal ramifications are firstly, you should be vigilant about having
good and working operation and airworthiness systems and secondly, if you do
have a serious accident, you should have your "house in order" so the
opportunities for legal avenues by other parties are minimised.  If you can
demonstrate good systems and consistent good management of safety, it is
less likely you will be successfully prosectued.

If Gliding continues to ignore proper investigation because of being afraid
of prosecution, this is folly in the long term.  Invesigations and the
dissemination of the lessons will help us all to avoid future accidents.
For GFA representatives we need to provide them with tools and training in
investigation techniques.  We need to include basics of incident causation,
reporting and investigation in our Instructor training.   If it is a concern
of investigators being prosecuted, we need to investigate some form of
liablity insurance for them.  These are things for the GFA Ops panel to take
on if they would listen.

As an aside, I have had opportunity to see a number of GPS traces from
outlanding incidents and accidents, and some random traces from "non"
incidents from inexperienced cross country pilots (from various clubs), and
they show a remarkable similarity on the lack of decision or discipline to
break off, which was a contributing factor in the fatality at Dalby.  If we
had consistent reporting and investigation this is the sort of information
that should feed back into our training systems and to all the club
instructors.

Jenny Thompson








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