Recent RA-Aus fatal accident history

[John Brandon]

There appears to me to be a definite link from training standard to behavioural standard to results with the current elevated levels John.One possible cause is that RAA has left itself open by not having a management level above instructors.

Although this then makes instructors responsible for the behaviour of their students until they move out of the instructor's area, not too many understand this, and there are a few who stand by and spectate on bad behaviour, making comments such as "you can only teach them so much" and not realising that they have an obligation to ground the miscreant.

I quite agree that the link you describe must exist. I guess students and others all see the instructors as the frontline RA-Aus operation managers, but as you suggest not all instructors understand their responsibilities in this regard and may fail to inform the CFI that his/her grounding options for pilots and aircraft allowed by the ops manual section 4.01 para. 6 should be exercised. By the way that para has existed for at least 19 years but I have not seen any elucidation of it.

 

John

 

 

[turboplanner]

Which points to a culture issue which needs to be addressed.

 

In reference to your cases John, I'd suggest, even from tracking them down on this site that the number of fatals per year are nearly double what you've found. People here are astute at posting news reports about incidents and fortunately we often get better information about the details than ever shows up officially. Tracking them down by search though is another matter, with thread titles like "Oh no, not another one" which could be anything from another engine failure in a series to another new xxxx aircraft. Each time I think "I should try to database them" I get busy at work.

 

 

[damkia]

Which points to a culture issue which needs to be addressed.In reference to your cases John, I'd suggest, even from tracking them down on this site that the number of fatals per year are nearly double what you've found. People here are astute at posting news reports about incidents and fortunately we often get better information about the details than ever shows up officially. Tracking them down by search though is another matter, with thread titles like "Oh no, not another one" which could be anything from another engine failure in a series to another new xxxx aircraft. Each time I think "I should try to database them" I get busy at work.

In relation to this issue, perhaps it would be useful if people simply used a standard heading in the appropriate subforum along these lines

INCIDENT: <Location>, <Aircraft>, <Class, eg, LSA/GA/RPT>, <Date>, <Brief summary, eg, EFATO, Structural failure - wing, Loss of separation, Near miss>

 

Could this be included in the "read me" at the top of the accidents and incidents forum?

 

It would be interesting to see what would happen if CASA noted that the information gathered/presented by this site exceeded that provided to members by RAA...

 

 

[turboplanner]

Anyone who thinks Human factors training is going to stop fatal accidents in any form of aviation has there hand firmly fastened to their nether regions.

I'm not sure whether it was CASA or the competing ATSB [there's a structural stuff up for a start] which found that Human Factors were the main cause of a large number of accidents.

 

The next step is where it all went wrong, and we were made to study the effects of a diver catching a crayfish one minute and rocketing up to altitude the next - a possible situation, but not based on hundreds of skin divers exploding at altitude.

 

Deciding that "once you learn how to ride a bike you never forget" and applying that to flying once a year and thinking you're going to remember correct radio procedure, including changes, navigation procedures from memory, checks while actually identifying, forced landing procedures without missing a vital item, crosswind, windshear reaction etc, I would consider to be in the human factors area. So, for example let's say you were originally taught five years ago that the first action in a forced landing was to trim the aircraft to glide speed, but today you were a bit hazy, or as one well known person likes to do, give your mayday call first, "so people can find you" and spend the 14 seconds it takes to do that, on top of the original "what the hell is happening" delay, you could find yourself stalled or in a spin, and I'd suggest that would be HF, fixable by recency training or practice.

 

That might or might not be a good example, but my point is that HF needs another visit to align it with actual cases, so people have a clearer understanding on what corrective training or practice they can do to eliminate that risk.

 

 

[damkia]

HF needs to be revisited every licence renewal time in order to reflect the increasing base of knowledge and experience gained in the area by way of incident investigations. HF is not a static base of knowledge.

 

 

[motzartmerv]

Yes tubz, i agree. I was saying that no amount of HF training is ever going to stop accidents. We train people how to land, and they still have landing accidents etc.

 

In the situation you described the pilot having been trained 5 years ago, while it could deffinatly be a human factos issue, i still suggest that airmanship would be lacking if this guy had not done any refresher training in the 5 year, not done any prcatice PFL's, not done any during BFR's, not insisted on getting some dual if he felt he was getting hazy on the procedure. I don't think the HF testing is the right way to go. It misses the mark completely.

 

 

[turboplanner]

I'm saying its HF only in the sense that a pilot exhibiting airmanship will have meticulously done all the things you are saying, and leaving aside the dropkicks who think that's all crap and they always fly safe, that a normally meticulous pilot just didn't get around to bringing himself up to date on something and BINGO that caused the crash - I'd group that into Human Factors.

 

What is definitely needed is a clear explanation of what Human Factors cause the accidents CASA/ATSB found, and a live document on the CASA/ATSB website listing HF failures so we don't have tests about divers rather than the most common HF issues.

 

 

[REastwood]

So, the only statistic that sport and recreational aviation should be striving for is 'zero'; no fatal accidents and no crippling injuries.

This one statement is being echoed across many industries and endeavours which basically translates to "we must have perfection." I do not see how this can be practically achievable. Certainly if we stop all aircraft flying, remove all cars off the road, incapacitate all earthmoving equipment then society will reduce the number of accidents these forms of machinery causes. To bring it to zero all aircraft, cars and earthmovers must be destroyed and every person on the planet carefully monitored so that they do not build one secretly in a shed. Society will have to expend a near infinite amount of energy, time and restrictions to bring about a zero injury result.

 

A lot of facets of life can be described by a bell curve, society can move the bell curve left or right by implementing various policies or lack thereof, but you will always have a low minority, a majority in the middle and a high minority. I personally partake in aviation, motoring and earthmoving. I actively try to avoid death and injury by being responsible in the actions I undertake when performing various activities. I receive training and know that instructors do not know everything, therefore I must be responsible in actively seeking as much knowledge and skills as I can. I am also aware that circumstances beyond my control may impact on my safety and I can try to mitigate or reduce the probability of those circumstances but there is always a chance that I may die or be injured and there is nothing I can do about it. Society can help by removing the outwardly dangerous people away from the populace but I also can make sure I do not associate with outwardly dangerous people as well.

 

Society should strive for what is best for the majority, a balance between protection, cost and freedom. Members of society should take responsibility for their own actions in balance with the rules and customs of their society. Societies should grow not become strangled or free-for-alls.

 

Certainly accidents should be investigated, all knowledge is important. Training facilities should meet a required standard, those not up to scratch need to lift their game or be shut down. Pilots need to be aware of their own abilities and the dangers posed to them. However, there will always be those people who do not want to follow the rules, be responsible and will do what they like. Society and/or fate usually catches up with them in the end but no amount of regulation apart from the removal of all free will can stop these people.

 

 

[nomadpete]

Nev, Human factors is not just a load of ass covering BS. It is stuff that we must regularly remind ourselves of rather than ignore. However, nobody was claiming that it is the sole answer to the hazard management that we must observe whenever we do anything (even flying!).

 

The other issue that has been rightfully raised (and it is a human factor) is the safety CULTURE of each pilot. This culture is a combination of the pilot's learned behaviour and the person's deeply ingrained character. Some are just incurable cowboys no matter what their CFI may try to instill in them. Some are naturally cautious and courteous. Happily I find that our CFI and most club members arent too hung up to make a comment when required. And since it is done kindly, the culture is pretty good.

 

Anyway, until the rest overcome our natural tendency to quietly mutter to ourselves under our breath, when we see somebody do something dodgy, the culture won't improve.

 

We all have a duty of care to improve the culture of our fellow pilots, if only to keep the bureaucrats from putting the hobbles on our sport.

 

And another thing .... Accident reports are essential.

 

Just my take on the safety issue.

 

 

[turboplanner]

re: REastwood post

 

I posted that I worked in a dangerous sport that went from a death rate about the same as RA to zero, and has maintained that zero for nearly fifty years.

 

To use your argument, we did not stop all race cars operating, nor did we destroy every one of them on the planet, nor did we ensure no one built one secretly in a shed.

 

Nor, by the way did we ask the drivers to slow down, and speeds are faster today than they ever were, which debunks another myth loved by automotive bureacrats.

 

We have achieved this in the state of Victoria, but not most of the other states, and even in Victoria there is no guarantee that this will continue forever without constant vigilance.

 

Please note the words John Gardon used - "striving for"

 

It is extremely hard squeezing out the last few problems, but that doesn't mean we should just give up and do nothing and then hypocritically offer sympathy when the next statistic pushes off the planet. In just one area alone, the ability to keep an aircraft gliding when the engine stops - if we had addressed that a couple of years ago we would have reduced fatalities by maybe 50% in the era we're talking about.

 

Very rarely will you ever get to zero for the reasons you say, and what the governments have done is to try and place the costs on the people who take the greatest risk, but I don't think that's a debate we need to have at this stage when as Motz said, we don't even get reports to learn from.

 

 

[turboplanner]

Some are just incurable cowboys no matter what their CFI may try to instil in them.

These are the ones I was thinking about earlier; they are heavily represented in the statistics. It's well worth reading the Barry Hempel debate over on another forum - it has dragged in operators, managers the medical profession, CASA and a lot of others and shows what can happen when you turn a blind eye.

 

At the present time in RAA the CFI's are the ones who signed off those cowboys to operate, no one else so the responsibility rests with them for the bad conduct, unless a layer of auditing and enforcement people takes over that role.

 

 

[nomadpete]

"At the present time in RAA the CFI's are the ones who signed off those cowboys to operate, no one else so the responsibility rests with them for the bad conduct, unless a layer of auditing and enforcement people takes over that role. "

 

That's what a BFR is for. I wonder how many CFI's would be brave enough to use that opportunity to penalise (ground) these people who are dragging down the reputation and ultimately thesafety record of RAAus ?

 

 

[damkia]

@ REastwood

 

As someone that now works in OHS/WHS I can say I could not agree more.

 

@ John Brandon

 

Zero accident/incidents are not achievable when you cannot control all hazards.

 

http://www.smartohs.com.au/site/files/ul/data_text30/1363739.pdf

 

The thing about this hierarchy is that only Elimination is capable of reducing the risk from a particular hazard to zero - everything else under elimination in that list has a residual risk profile, ie there will be some extraordinary circumstances sometime that will trip the "one in a million" event, and in fact that is why it is a one in a million. "Beware the ones..." I am saying that we should try to reduce our risk profile by constantly reviewing and reassessing other options, not simply giving up all attempts at risk reduction.

 

There is also the small matter of the frailty of the human mind and body - we are not perfect, nor will we ever be. What do you do about an outwardly fit and healthy 30 yr old that has a heart attack in a loaded 200 tonne dump truck going up a a ramp in an open cut mine? How about a staff member that has his first psychotic event whilst in possession of 8 tonnes of ANFO with detonators, wiring, and charge box in his possession?

 

The environment can also play some pretty extreme tricks too. Remember a couple of months ago about that guy in Florida that went to bed, only to die in his bed from being consumed in a sink hole?

 

There is a baseline random element to risks that is is simply not possible to gauge.

 

“

 

 

 

 

 

 

There are known knowns; there are things we know that we know.

 

There are known unknowns; that is to say, there are things that we now know we don't know.

 

But there are also unknown unknowns – there are things we do not know we don’t know.

 

”

 

 

 

 

 

 

 

 

—

 

 

 

United States Secretary of Defense, Donald Rumsfeld

 

 

 

 

 

(One of the more intelligent things he did come out with...)

 

Zero accidents/incidents is a great line for upper management to throw around to give the appearance of being serious and proactive, indeed it is not frowned upon by most OHS people as an ideal. Most if not all OHS staff realise that is is not a practical scenario, and that the reality is you can only manage your risk profile, not eliminate it altogether, leading to the non-zero accident/incident rates that are usually seen for the reasons stated above.

 

 

[turboplanner]

Dankia, if you don't have a target, how are you going to hit the bullseye?

 

 

[motzartmerv]

At the present time in RAA the CFI's are the ones who signed off those cowboys to operate, no one else so the responsibility rests with them for the bad conduct,

Thats a bit of a bland statement there tubz. using your example, was it the CFI who signed out Barry that should be responsible for his behaviour?. I think not. Are students who are under direct supervison of a CFI represented in the stats? I dont hink they are, and then and only then can we blame "the CFI who signed the cowboy out" . Any cowboy can fly well during a BFR or flight test, or can hide their real personality during training, and if that cowboy buys his own plane, or flys elsehwre how can the CFI have any direct input into his flying from then on?. Its true that the CFI must do his/her best to sintill good airmanship etc in all people he flies with, but the industry as a whole need to take responsibility for allowing this cowboy mentality to infect our ranks. An example: Temora last year, Ian and his wife departed with less then 10 minutes of light left for a half an hour flight..The result, 2 dead trike pilots. Now was it the CFI who signed him out 10 years ago's responsibility?. Or was it my responsibility as the last CFI to reprimand him on flying behaviour?. I chipped him twice on unsafe practices in the cct and joining. We had several discussions and I was happy with his response and subsequent flying.At Temora, natfly, he felt it was ok to demonstrate this type of behaviour in front of all that were present at natfly. This is totally unacceptable from all our points of view. We ALL are responsible for the culture, what a sad indication of that culture when a pilot can think its ok in front of all his peers to takeoff and fly away into the darkness.. That is ALL our problem.. it points to a severe lack of safety culture within our organization. We cant hang it on the CFI who gave these guys a ticket, perhaps sometimes the CFI could have a degree of responsibility in some cases, but blanket blame like that doesnt help anybody. If we accept and allow cowboy behaviour, then we must accept and allow the cowboy related deaths.. Simple..

 

 

[damkia]

Dankia, if you don't have a target, how are you going to hit the bullseye?

I said that zero accidents/incidents is the ideal (the target), even for OHS Staff, and that we as OHS staff are interested in lowering the risk profile/eliminating hazards as much as possible. The "randoms" and other "non-zero" risk profiles from things I mentioned we have no control over are the things that make the Zero concept come unstuck.

 

 

[turboplanner]

I'm not sure of the structure Barry was under - I don't think it was RAA, and I suspect it was CASA in which case there's an audit level beyond instructors. I haven't looked at the warbirds structure.

 

I didn't mean to imply that the original CFI had the duty of care for life - it could be the pilot's current instructor, or the CFI whose area he regularly flies in.

 

When the spotlight is turned on to an RAA crash, and the victims want to know who was responsible, then who else do you point to?

 

 

[motzartmerv]

The pilot!!!!

 

 

[turboplanner]

Sometimes, but in the case where he was unable to set the aircraft in a glide or meet other syllabus requirements that means he wasn't capable of safe operation - either his training or his assessment failed (and I would class recency in with that)

 

If he was misbehaving on a regular basis, remember that RAA is a self administering body. Someone already mentioned there are provisions there to deal with him.

 

 

[motzartmerv]

Yes but it's very difficult to guage an measure how a pilot behaves when he's not with you. If he doesn't practice pfl before he's due for a BFR, then spends an hour refreshing before the chief jumps in, an he demos a reasonable pfl then the CFI can issue the BFR in accordance with the ops manual .

 

 

[turboplanner]

I know, and to be fair, if he remembered to do it correctly he has probably studies to bring his recency up to date, so I would pass him too (if I was an instructor)

 

The issues will come with the square pegs in the round holes ones who leave a trail of incidents and youtube videos doing beatups etc.

 

"person of reasonable intelligence knew or ought to have known" is a phrase I've seen a few times.

 

I wonder how many of those have ever had their Certificate suspended?

 

 

[nomadpete]

The CFI and BFR issue: If a pilot has been getting noticed for irresponsible behaviour, or perhaps lapses of skill, then it behoves the CFI to take that into account as well as the actual performance during the BFR. However, I feel that our culture does not go far enough to support the brave CFI who sincerely wants to take action to get a pilot to improve his culture or skill level. After all it will involve a loss of face for the pilot in question, and impose the expense of further training ( and risks the counter argument that "he's not all that bad" and the CFI stands to make money out of it, etc ....) It undoubtably would cause some ill feeling. So we need to offer better support to our CFI's if we are to use them to be the air policemen. As has been pointed out there is not much in our 'self regulation' to allow control. We really don't want to end up with heavy handed government regulation and if we are to be allowed to self regulate then it is up to US the members to regulate those who are creating our cowboy reputation, and those who should do more training.

 

 

[turboplanner]

As has been pointed out there is not much in our 'self regulation' to allow control.

Are the bells ringing?

 

We are in a performance era - prescriptive legislation is largely a thing of the past; self regulation is exactly that and RAA has left a safety are uncovered, and needs to do something about it.

 

That's where the Incorporated Association structure is so good. It's relatively simple to introduce a Safety Audit/Management structure, write the audit, enforcement and sanctio structure, appeals structure etc. and take that load off the CFI and instructor, at the same time auditing their performance.

 

If you roll up to a Sporting Shooters day and the range officer isn't there nothing happens, if you roll up to a speedway and the Chief Steward isn't there, nothing happens. If you roll up to an airfield it's a free for all

 

 

[nomadpete]

I work in an industry that has some low probability hazards that offer high consequences. We say "one flash and you're ash". Kind of like when I get into a RAAus machine. If my employer can set targets as below, why can't RAAus?

 

"We acknowledge that our goal to have a high performance safety culture is something that will take time and we are aiming for a three year timeframe. The Safety Roadmap provides the framework for how we will reach our goal. This will help define why safety is important at "XXXXX" and it will help communicate the safety initiatives to come."

 

 

Sure it has its element of BS but I would like to point out that although we all joke about our management's "over the top" safety BS, we have probably got the world lowest death toll in a hazardous industry. I note that our last three fatalities were caused by left field unforseeable events like lightning strikes, and momentary blond moments. Our safety record is the result of a strongly fostered SAFETY CULTURE. And leadership comes from the top.

 

It works.

 

 

[motzartmerv]

Agreed. The problem is complex and as someone who has tried to improv things by talks with te raa etc with regard to specific breaches I can tell you that the culture is lacking all the way to the top. There's a real dobbers wear nappies syndrome in the raa, and when you do try and help you get ostrisized and cop comments like" you just think your better than everyone else". And to be honest I'm over it . I just sit on my hands these days unless its one of my students/ pilots or te behavior is effecting them directly. I am often affronted with rubbish instructing and blatant disregard for the rules, an the wringer I get out through when making a complaint has warded me off submitting anything. Sad but true I'm afraid.