Culture change needed

[Bandit12]

Andy, your summation is clear and succinct.

 

 

[Guest trishok]

Motor Vehicle Registration renewals in NSW require a motor car over 5 years of age to undergo an annual roadworthy inspection by a qualified and Road Transport Authority Approved Mechanic at the Authorised Inspection Station. This is a R.T.A. Pink A4 form called SAFETY INSPECTION REPORT.

 

This form is a Legal Document

 

Requires the following information:

 

Vehicle Owner details

 

Vehicle Details

 

Reason for Inspection (Registration Renewal/Change of Ownership/Clear Defect Notice/Unregistered Vehicle).

 

If Clear Defect Notice - itemises Defect Notice Number/s.

 

INSPECTION CHECKLIST

 

Vehicle Identification

 

Brakes (test printout must be attached)

 

Steering and Suspension

 

Wheels and Tyres

 

Body Condition

 

Seats and seat belts

 

Lights and headlight aim

 

Engine/driveline

 

Exhaust system

 

Towing attachment

 

LPG system (qualified examiners only)

 

Number Plates (obscured, faded, unauthorised)

 

NO DANGEROUS PROTRUSIONS FITTED (I.E BRACKETS FOR SPOTLIGHT, FISHING ROD HOLDERS ETC.

 

 

[facthunter]

I agree with the summation and I am most concerned about it. The person who has built the entire aeroplane would be more able to determine it's condition than or "just any" L2 This is the sort of inappropriate over-reaction that can serously cripple the "essence" of RAAus which is Limited but acceptable risk for informed participants to a max of 2 in the plane. The discovery of the "deficiencies" was incidental and not in any way the cause of the incident. bad times ahead if this sort of thing is accepted. It is a recommendation at this stage. Nev

 

 

[Guest trishok]

The fact that it is not mandatory to obtain a safety certificate for recreational aircraft registration renewals on an annual basis and it is for a motor vehicle registration renewal on an annual basis, was a major concern for the Coroner.

 

 

[facthunter]

In Victoria that test is only required when the vehicle is sold and is continuing to be used on the road. There has never been established that the money spent has produced a result ( Improvement in safety) commensurate with the cost outlay. Vehicles are sometimes pulled over and given a random satey check which can result in the vehicle being required to be repaired. They usually get things like minor oil leaks from the rear mainbearing and Diff pinion seal and cracked lenses.

 

For the aircraft AD's come out and it is inspected before every flight. Any likely damage is checked (Like a heavy landing bird strikeetc) Totally different thing to a car where most drivers do not even check that their tyres are inflated. The comparison is NOT VALID. Nev

 

 

[Guest trishok]

Queensland also does not mandate annual registration vehicle safety checks.

 

Many vehicles purchased from Queensland are unsafe vehicles that do not pass registration requirements in NSW and if inspected, are considered dangerous.

 

 

[Guest Andys@coffs]

The fact that it is not mandatory to obtain a safety certificate for recreational aircraft registration renewals on an annual basis and it is for a motor vehicle registration renewal on an annual basis, was a major concern for the Coroner.

Trish ( I mean no dissrespect to you personally)

 

Use of the NSW approach to motor vehicle roadworthiness is a very poor example to use. NSW is unique in its approach to motor vehicles. Almost all other states DO NOT perform similar checks. If this made us safer than the other states then it would be clear to see that NSW accident statistics would be better than other states and that is simply not the case or the remaining states would have adopted the NSW approach.

 

I see the "NSW way" evident where NSW residents now have choice in compulsory 3rd party insurance but as a result of that "Improvement" now pay the most for a premium when comapred to any other state because previously a gov dept negotiated on behalf of the entire state, and had qualified and experienced people doing that negotiation and now its every mum and dad that has a car most of who cant spell negotiate let alone do it, and even if they could what buying power do they bring to the transaction?????

 

In fact I would have to say that using anything the NSW government does in general should be used as an example of how not to do something, not how to do it....

 

Before moving to NSW I lived in SA, and in SA there is No check on a motor vehicle in the years that an owner owns it unless the police direct that it be inspected, in which case inspection is done by the department, not a commercial entity.

 

Andy

 

 

[facthunter]

A car is not an aeroplane and an aeroplane is not a car. Most people only lift their car bonnet if there is smoke or steam coming out of it. They operate in a totally different environment. An aeroplane can become unsafe at the next landing but may have little or no obvious damage. Does a car have a log book that lists all mandatory work done and signed off.? An aeroplane is operated from one flight to the next with mandatory checks built into it's POH . Do you fly a plane trishok and what is your place in all this? Nev

 

 

[Guest Andys@coffs]

Nev Trish is the Grandmother of the deceased pilot. She brings a personal experience to this tragedy and IMHO is entitled to state a position.

 

Where we know that position to be wrong we should be able to discuss rationally (Not saying you havent), but best outcome is that we change her mind through the application of logic and education than sheer weight of numbers....

 

Andy

 

 

[turboplanner]

.What have I over simplified?

Andy

Quite a bit I think.

 

A lot depends on what evidence was produced. Remember the Coroner is only looking at the cause of death. Who was responsible is another matter, and I would expect different evidence to be presented when someone is deciding who is going to look after the families.

 

The annual inspection is a bit of a false trail - in some respects I'd see that as sloppy compared to requiring airworthiness at all times, and also don't forget this is just one State jurisdiction. There are better ways of tightening up than that.

 

 

[Guest trishok]

Facthunter, I do understand where you are coming from.

 

However it is a Coroner for the State of New South Wales, sitting at Lismore, Magistrate Jeff Linden, who has referred his Recommendation iv) (outlined previously) to the Federal Minster for Transport, the Hon Anthony Albanese.

 

The photos, in full colour of the rust condition of the plane, when it was for sale by the previous owner, were shown to the Coroner.

 

Facthunter, Don't shoot me, I'm just the messenger.

 

I am the grandmother of the pilot and his friend, who both died in the crash.

 

I am relaying information to your forum because two years ago the members were complaining of lack of information about any results from crash investigations that may help them stay safe, and prevent further accidents and deaths.

 

 

[facthunter]

I genuinely wanted to know what the posters position was and I hadn't read the detail of the previous posts. In my case I have lost 5 friends in the last 8 years or so and I believe that virtually all those deaths were preventable in ideal circumstances . Aviation safety is one of the main reasons I post on this forum , so we have the same aim, though I am probably more boringly persistent in it than most want. I don't believe the concept of an annual inspection would do much more that APPEAR to be doing something, and in aviation we don't need that sort of "fix". Nev

 

 

[FlyingVizsla]

Trish,

 

Thank you so much for the information from the Coroner's Inquest. This is what we have been sorely lacking and gives us a chance to discuss what really did go wrong and what we could do better, as people, plane owners, pilots, members and stakeholders in our regulatory bodies. There have been calls to see more of these. You have great courage and concern, which I deeply admire and a staid honesty and logic which defies the tragedy you have endured. Please don't be offended as we now discuss the implications of some of the recommendations. Without such robust discussion there cannot be a workable solution.

 

Thanks again. I too, have lost friends in "preventable" accidents. Would love to meet you one day.

 

Sue

 

 

[Guest trishok]

Thank you Sue and (Facthunter (I'm one of them too!)),

 

In this Coronial Inquest the cause of the deaths was indisputable.

 

The Mother of the deceased passenger, wrote to the Coroner following the accident with many valid questions, which were mostly answered during the Inquiry.

 

Please refer to the Northern Star Newspaper Article, the first thread of this matter.

 

NSW does seem to have tougher laws re vehicle inspections than other state.

 

 

[facthunter]

Trish, I have seen corrosion in planes that operate commercially and checked frequently and often only picked up by chance or by a direction resulting from a fatality. Often it's well hidden.)

 

An L2 would have had to do a condition report at the time of transfer to comply with the RAAus rules. I don't know how long ago the transfer was done but if it was in the last 12 months the rule the coroner want's would have in effect, at the time of transfer, been carried out. It's a condition report that is done. but it should pick up the sort of things that would be a problem

 

I will tell you that I would not want to be an L2 because the system may end up putting so much liability on him if this is implimented that their position is untenable. Corrosion is a difficult thing to check in some instances well nigh imposible withiut the most advanced Non destructive testing which is prohibitively costly. The system as we operate it puts the main responsibility on the owner/operator as it actually does in larger aircraft too. The owner has to ensure that all required maintenance/ inspections are done, in that case by a suitably qualified person.

 

Non school planes under RAAus can be maintained by the owner.. The owner has a vested interest in keeping the plane safe because he is in it. A lot of knowledge is required to do this well and is best obtained from the collective knowledge of all the owners of that Marque. No L2 can be across all types because they are built so differently. Nev

 

 

[Guest trishok]

Nev,

 

I listened intently to everything said during the Inquest, because I, too, am a facthunter...

 

During my working career I have worked alongside forensic pathologists as a histopathology transcriptionist.

 

These men and women were brilliant histopathologists and scientists.

 

We were responsible for coroner's autopsies, amongst other matters.

 

Study of pathology and analyses of the root cause of accidents, disease and other problems, is essential for the prevention of accidents, disease and other problems in health and welfare of human beings.

 

The Coroner in this horrible tragedy was ably assisted by expert professionals from various fields of knowledge and experience.

 

In my opinion, the Inquiry was a forensic investigation drawing conclusions that could perhaps prevent further tragedies. This Inquiry was not merely to determine cause of death. It was considered a matter of public interest with the aim of making changes to the existing way of operation.

 

The solicitor for the passenger's mother left no stone unturned in seeking evidence to present to the Coroner. They wanted questions answered and suggested recommendations to help prevent such accidents.

 

It was determined that this accident causing death was entirely preventable.

 

The Coroner made his recommendations with the help of experts, including Detective Inspector Hurley.

 

 

[Bandit12]

It is true that often a coroner will make comment about other findings not directly related to the cause of death but uncovered in the process of determining cause of death. One of the reasons for this is also because the coroner can hear information not totally related to the death, and also information that would never have been admissable in a criminal court. My lovely better half regularly prepares briefs for the coroner in Victoria regarding deaths due to fire or explosives, and the scope of a coroner's authority and recommendation is very wide.

 

With all that said, it seems that RA-Aus may have benefited from providing what information and recommendations it could to the coroner in a proactive manner prior to the investigation concluding, rather than waiting for a bunch of unrelated findings to be brought to the attention of our transport minister......

 

 

[FlyingVizsla]

Very good to hear first hand, and from a credible witness (good on you Trish), that this Coroner's inquest wasn't just a bunch of non aviation types showing their ignorance. Well done to all concerned!

 

People, we need to be very clear on who we direct our comments to. Trish is not the Coroner who made these recommendations which we are beginning to debate. These recommendations will be passed to RAA / CASA to debate, action, legislate or ignore. Put your thoughts out there on this forum in a logical and sensible way, then convey them to your board members, reps, CASA etc. Participate in the Notice of Proposed Rule Making (NPRM) process with CASA, have input to the Tech Ops Manual, Get involved, have your say, but don't attack the family - and fight fair amongst yourselves.

 

 

My considered opinion will follow.

 

Sue

 

 

[Guest trishok]

These recommendations will be passed to RAA / CASA to debate, action, legislate or ignore. Put your thoughts out there on this forum in a logical and sensible way, then convey them to your board members, reps, CASA etc. Participate in the Notice of Proposed Rule Making (NPRM) process with CASA, have input to the Tech Ops Manual, Get involved, have your say, but don't attack the family - and fight fair amongst yourselves.

 

 

My considered opinion will follow.

 

Sue

 

Also

 

With all that said, it seems that RA-Aus may have benefited from providing what information and recommendations it could to the coroner in a proactive manner prior to the investigation concluding, rather than waiting for a bunch of unrelated findings to be brought to the attention of our transport minister......

 

Shane

 

Agree with Sue and Shane. You all are sensible people. I hope you will Be proactive. Debate rationally and

 

Listen to Sue. (I think she is a legal person).

 

And please consider the following :

 

Note that CASA has drafted regulation guidelines for psychiatrist medical examiners of prospective pilots who had been diagnosed with childhood ADHD (October 2010)

 

From the internet, titled:

 

"Designated Aviation Medical Examiner's Handbook"

 

Approved by Assistant Director, Aviation Safety Standards Version 3.7:October 2010

 

2.6 Psychiatry

 

Pages 2-6:5 to 2-6:13 : Disorders Diagnosed in Childhood

 

Aereomedical Management Protocol in Attention Deficit Hyperactivity Disorder (ADHD) -

 

And Please note the following:

 

Behind the wheel with ADHD, Advice to physicians, parents etc:

 

Motor vehicle (MV) accidents are the leading cause of death for 15- to 19-year-olds in the United States; they are responsible for 1 in 3 deaths in this age group.[1] Two of 3 teen fatalities are young men.[1] Although 15- to 20-year-olds comprise only 6.4% of all licensed US drivers, they are responsible for 19% of annual MV deaths.[2] Because of their immaturity, young drivers take more risks (eg, speeding). Because of their inexperience, they tend to underestimate driving risks and overestimate their abilities to respond to dangerous situations.[3,4] Among all novice drivers, the 6 factors most associated with high rates of MV crashes are impulsivity, inattention, poor judgment, distractions, aggression, and impaired executive function skills.[5-7] It should not be surprising, therefore, that young drivers with attention-deficit/hyperactivity disorder (ADHD) appear to be over-represented in the MV crash and fatality statistics. This is attributed to the twin threats of being a novice driver and having 1 or more ADHD-related traits that increase crash risk (Table 1).

 

Table 1. Factors Associated With High Rates of Motor Vehicle Crashes

 

Factors Associated With All Young Adult Drivers

 

 

 

 

 

 

 

 

Factors Associated With Young Adult Drivers Who Have ADHD

 

 

 

 

 

 

 

 

Immaturity

 

 

 

 

 

 

 

 

Immaturity

 

 

 

 

 

 

 

 

Inexperience

 

 

 

 

 

 

 

 

Inexperience

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Impulsivity

 

 

 

 

 

 

 

 

Inattention

 

 

 

 

 

 

 

 

Poor judgment

 

 

 

 

 

 

 

 

Distractions

 

 

 

 

 

 

 

 

Aggression

 

 

 

 

 

 

 

 

Impaired executive function skills

 

 

 

 

 

 

Note: immaturity and inexperience that increase driving risks for all young adult drivers are compounded by additional risks associated with ADHD symptoms, leading to poorer driving outcomes among those with ADHD.

 

Prospective and retrospective studies, drawn both from community samples[8,9] and clinic-based patients,[10-14] have documented that, compared with their peers without ADHD, young drivers with ADHD have:

 

·2-4 times the risk for an MV accident when driving;

 

·3 times the risk of having an accident with physical injury;

 

·4 times the risk of being at fault in an accident;

 

·6-8 times the incidence of a past driver's license suspension.[15]

 

Similar driving problems and histories also have been documented in older adult patients with ADHD.[16] In fact, 1 recent study indicated that

 

the simulated driving performance of sober, unmedicated adults with ADHD was impaired to a similar degree as alcohol-intoxicated adults without ADHD.[17]

 

Advise Teens That They Should Never Drive Aggressively or When They Are Angry

 

After an argument with a parent or friend, an adolescent with ADHD may feel that storming off and going for a drive is an attractive way for them to "cool off." However, both adults with ADHD and college students with many ADHD symptoms have reported more aggression and reactive anger while driving than comparison subjects without ADHD.[47,48]

 

Recently, Barkley hypothesized that "deficient emotional self-regulation (DESR)" should be added to the classic triad of inattention, impulsivity, and hyperactivity, as a core diagnostic component of ADHD.[49] He cites low frustration tolerance, impatience, and quickness to anger among signs of DESR that may adversely affect driving behaviors.[49] Drivers with ADHD need to be taught that aggressive driving is dangerous. Increased awareness of DESR, and conscious modulation of anger and irritability should be discussed frequently during driver training and beyond. Youth with ADHD will need to stay aware of their reactions and work to stay calm while driving, no matter what other drivers do.

 

T

 

 

[FlyingVizsla]

RECOMMENDATION

 

1. a) RA-Aus reinforce to its members that there should always be positive obligations on all members to report any illegal or dangerous flying that might be in contravention of the Operations Manual and/or Regulations.

 

b) RA-Aus reinforce to its members that any evidence suggesting illegal, dangerous or unsafe flying on a passenger-carrying flight requires a member pilot, Instructor, Senior Instructor, or Chief Flying Instructor, to make an immediate mandatory notification to the Operations Manager.

 

2. RA-Aus review its system for receiving and handling complaints about member pilots that relate to flight safety issues, including:

 

a) developing a procedure for documenting these complaints;

 

b) developing a procedure for investigating these complaints;

 

c) developing procedures to protect a person who lodges a complaint, including an anonymous complaints system if appropriate.

 

RAA already has an informal system - you can phone, write, email the Tech/Ops Manager with concerns. What they lack is the funds and manpower to be everywhere, and maybe the investigative skills to properly mount a case. We might end up with a REPCON (CASA's anonymous reporting system), which, from their reports in the magazine seems to be they contact the company or pilot to see what their explanation is. Another difficulty is deciding what is dangerous flying and how that can be worded. To make it mandatory to report will put RAA requirements above those of CASA. As far as I know there is no Aviation legislation mandating a GA pilot (instructor or higher) to report other GA pilots. I think we will end up with a "policy statement" and a database.

 

The other issue is that RAA has no teeth. The worst they can do is cancel the membership (and hence the pilot certificate). They can't impound the aircraft, ban the (ex) pilot from airports, stop him getting in a plane or training for another type of license. No one checks licenses when you walk out on the tarmac and I daresay they could not publish him on a blacklist because of privacy concerns. I can't see this recommendation working in the form the Coroner intended. Not without a legal tome and a bevvy of inspectors, and the membership increase to pay for it.

 

I think our best strategy is to educate, applaud good airmanship, condemn risk taking, mentor young pilots, and get all the Coroner's reports, accident & incident reports, digest them and live.

 

Sue

 

 

[djpacro]

REPCON is the ATSB's system and I think you'll find that RAA operations are not excluded. In my experience it works well. Some of the REPCON's stories are published (de-identified) in Flight Safety magazine

 

 

[M61A1]

I am extremely appreciative of the factual evidence that has been brought out in the open.

 

What I struggle to get my little mind around in not just this case, but many, is, that despite legislation already in place prohibiting the behavior, they (magistrates/coroners) somehow think that making an extra rule that the same offenders (for want of a better term) will for some reason, decide that they will now follow that rule, despite disregard of the previous, or even worse, make another rule that makes someone else accountable for their (offender's) actions.

 

Something else to consider...... would proper spin training possibly prevented him from carrying out spins at too low an altitude? (as education,demonstrating altitude lost, recovery time, etc), as the reality is that spins can be safely carried out in the aircraft type used, just not legally. The aircraft doesn't know whether it's got VH or RAAus rego.

 

 

[motzartmerv]

I'd like to ask a question. Has anyone here ever reported an unsafe flying act, inaction, manouvre, attitude or anything at all to the raa? I don't want details, just a yes or no and what I want to know is what was the outcome of your notification?

 

Cheers

 

 

[Wayne T Mathews]

I'd like to ask a question. Has anyone here ever reported an unsafe flying act, inaction, manouvre, attitude or anything at all to the raa? I don't want details, just a yes or no and what I want to know is what was the outcome of your notification?Cheers

Answer to Q1/ Yes

 

Answer to Q2/ Nothing that I am aware of....

 

 

[djpacro]

Q1: Yes, via a REPCON. Q2: One doesn't necessarily hear any more - privacy rights work both ways. In this case I heard of some appropriate action taken. And, to fill in a bit of info as to why it was escalated - this person was head honcho of an organization so no-one was going to say anything to him that would be effective - he put my student and myself personally at risk so I wasn't just an observer.