Guest Andys@coffs Posted June 28, 2007 Posted June 28, 2007 I understand Mike that we have a board and executive, however I suspect that they are not qualified to undertake detailed crash investigation and analysis. I believe that ATSB investigators undertake over 2 months of training per year to maintain their status. As Ian can attest, it would be beneficial for the executive to sometimes seek direction and utilise the skills of association members. From the PM's and emails that I've already received we appear to have some high calibre individuals with us with regard to investigative qualifications and experience. Brent Interestingly I just got of the phone, having been discussing this forum thread with Lee Ungermann. The information that I received from Lee included:- 1) formal ATSB training into Crash investigation has occurred and is continuing to be applied more broadly within RAA 2) when growth rate is factored, our fatality rate doesn’t appear to be noticeably different than in previous years (yr by yr comparison), though I'll caveat that by saying that the statistics on which Lee drew that conclusion aren’t available to me, and by saying that if the rate were to continue for the remainder of the year at the same rate as we have been seeing so far this year then we would have a problem. 3) That many of the recent accidents which resulted in fatalities were in dual seat aircraft where the 2nd seat was occupied. That appears, based on historical data to be a statistical anomaly. 4) That at the moment, there is no regulatory pressure being brought to bear by the regulators (which is great, that means we are considering the issue well in advance of any potential mandated need.) 5) That the majority of recent concluded (and there are still some that are not concluded) investigations into fatalities show that in the main a poor decision (ie something that could have been foreseen and avoided) lead to the fatality. Human factors! Lee further went on to say that one statistic which is showing a problem is that we all have a legal obligation to annually report our hours and landings. Many (self included) have in the past not provided that information at certificate or registration renewal. As such the accident and incident rate is measured against only the hours and landings reported. Lee's contention is that we as a whole are under reporting our actual hours and as such the rates look much worse than they are. Having just renewed my 95.32 rego (without reporting the hours/landings) I intend to fix the oversight. Is there anyone else reading this that also has missed this important information from their renewals and can fix it? Regards Andy. P.S, it appears that in my last series of posts I took some grumpy pills at some earlier stage of the day. Apologies to anybody that was offended, it certainly wasn't my intent....Apologies also to those that couldn’t work out what the hell I was going on about. (too much workspeak)
Guest pelorus32 Posted June 28, 2007 Posted June 28, 2007 Embedded Safety I thought that I might take this discussion somewhere else. Please bear with me as I try to write these ideas out – they are forming as I’m writing and so I don’t claim this as a final well thought out position. Rather it is an item for further discussion. As organizations grow the things which happen in those organizations change and the properties of those organizations change. The systems theorists call these things “emergent properties”. I would argue that we are seeing some emergent properties about RAAus right now. As the organization undergoes enormous growth I think that complexity is emerging in the safety system which has probably not been there before. That generally means in organizations that the functional and structural responses that were previously sufficient are no longer sufficient. It is often not immediately obvious that there is a mismatch between the emerging properties/needs of the organization and the responses that have proved sufficient in the past. Additionally as human beings we are very good at adapting our responses to make them “sort of meet” the new demands. This further masks the gap that has appeared between demand and response. Ultimately some stimulus or stimuli will lead to a reassessment of the situation. I would characterize this whole thread as part of that stimulus. The people represented in this thread are in effect saying “we have an obvious problem and we are not certain that the response is sufficient or appropriate”. When the reassessment comes along organizations can adopt a number of ways of arriving at a solution. Often the best strategy is to identify proven strategies from elsewhere and to adapt them to your specific needs. In doing that we need to look at relevant examples and determine what they do. Probably the most useful points of reference are other aviation organizations. If we look at what they do we find – among other things – the presence of: 1.An effectively articulated and appropriately implemented Safety Management System; owned by 2.A Safety Directorate that is separate to and independent of Operations and that reports directly to the Board. Now, I’m the first to say that I haven’t conducted an exhaustive analysis of all the relevant organizational responses to safety. Nor do I intend to. What I am trying to say is that we have 7000 pilots out there. Whilst they don’t work for RAAus that organization does have a clear responsibility for ensuring their safe operation. That number of pilots is – I would hazard a guess – more than any airline in Australia for instance. It would appear on face value that our current safety response doesn’t measure up to the kind of responses elsewhere. Does that mean that I think we should get an SMS and a Safety Directorate? No it doesn’t! I’m not a safety expert. What do I want? I want an independent review of the safety processes of the organization with the intent of designing and implementing an appropriate safety response to the current and expected future demands of the organization. This review should be conducted by a person or persons with clearly demonstrated credentials in managing aviation safety. It should be commissioned by the Board. It should be overseen by a steering committee drawn from the Board (probably chaired by a Board member), the executive management, a CFI or two and some concerned and capable members. The review should be short and sharp, the terms of reference should be action focused and the outcomes should not be about “what’s causing these accidents?” but rather about “what organizational change is necessary for us to create an enhanced safety capability to deliver a safe operating environment for our organization in the future?”. We should expect that the whole thing could be done, dusted and implemented in 3 months. Once that happens we should have an enduring response to the emerging safety issues. Enough for now, but I would appreciate feedback on my half formed thoughts. I think that this is the sort of thing that we need to be saying to our Board. Kind regards Mike PS Great Post from Andy which he posted whilst I was writing. M
Yenn Posted June 28, 2007 Posted June 28, 2007 I have scanned through these posts and it appears the consensus is that the RAAus board does not know what it is doing. I may have misinterpreted peoples posts, so you can all howl me down, but I consider that our board is doing what it considers best for the association. I also consider that they would have a better grasp of the safety situation than I would and I suspect most of this forum members. How about letting them get on with the job and making sure that we do not contribute to the accident statistics.
Guest pelorus32 Posted June 28, 2007 Posted June 28, 2007 G'day Ian, I can only speak for myself: I think that the executive management and the Board are doing a good job. I also think that a lot of members have expressed concern about this issue. It is their responsibility to voice those concerns. There is also a difference between thinking that we have a good competent Board and thinking that there may be a variety of views out there which may contribute further. Mike
Guest Redair Posted June 28, 2007 Posted June 28, 2007 The review should be short and sharp, the terms of reference should be action focused and the outcomes should not be about “what’s causing these accidents?†M Mike, sounds like a plan. My only reservation however is with regard to not concerning ourselves with the causes of accidents. I am sure that it would be possible to give out detailed information on every factor that could be considered to be relevent to an accident and it's cause, yet to withhold all personal details. This I feel would give those pilots that are still learning, (which should in fact be EVERY pilot) a better understanding of how and why things go wrong. I do not wish it to be a "let's see who we can blame" excersie, but more of a "be aware of how the little things can develop" way of teaching, to try and increase the knowledge and hence the safety factor involved with aviation. And for anyone who thinks that they already know everything there is to know... well we'd been reading the reports about them first, I should imagine. Redair.
facthunter Posted June 28, 2007 Posted June 28, 2007 Accident reports. Unless these accidents are first analysed and the causal factors examined and the results made available, we will not progress the cause of safety in our movement. I can think of many examples in aviation where progress in safety matters was only forthcoming after (unfortunately) someone gets hurt or killed. The Aviation Safety Digest is an example of how to do it right, in it's coverage of these matters. The only good thing that can result from these unfortunate occurrences is to understand them so the likelihood of them being repeated is lessened or action/ modification taken where necessary. (example) Years of lobbying to get airborne radar in commercial Airliners in Australia achieved nothing,in the late 60's, But when an Ansett Viscount broke up just after entering a storm over Botany bay,immediately after take-off ,killing all on board, the opposition ceased overnight and the required radar was installed. Unfortunately, that is the pattern of these things. N...
vk3auu Posted June 28, 2007 Posted June 28, 2007 Quiet up front One of the problems today is that most people are learning behind more reliable engines, not the two strokes that some of us older ones had to master and they don't know how they will react when it actually does go quiet up front. I have had it happen twice so I can speak from some experience. Once was a broken crankshaft in an old Rotax 503 and the other was running out of fuel due to a headwind 8 minutes from home which was completely my own fault because I had the throttle open a bit more to compensate and the fuel usage was just a bit higher. It does make you much more cautious about the sort of terrain over which you fly. David
Guest pelorus32 Posted June 28, 2007 Posted June 28, 2007 I seem to keep doing this - failing to communicate effectively :;)3: I'm not for one moment suggesting that we don't need to know what causes each accident and to learn and change from that. Rather I'm asking a question about what sort of safety structure we want in place in our organisation in the future IN ORDER to be able to more effectively analyse accidents, develop strategies to enhance safety... What I wanted to separate was a review about future safety structure and process in our organisation from a review of these specific accidents. I think the latter is the role of the management team, the former a much more strategic task to be owned by the Board. Here's a question that might be looked at in a review and maybe a position taken to government: Lee Ungerman in discussing accident investigation at Narromine this year made it clear that the police and coroner "owned" RAAus accidents. That meant as I understand it that we had to await their outcome and their agreement before we can discuss accident causes and our findings. This clearly is not the case with accidents investigated by ATSB. As I understand it specific legislation enables and protects ATSB's role and actions. We are going to have over 8000 members - probably by the end of this year. Maybe it's time to be lobbying government to legislate to allow us the same kind of access and protection that ATSB has. Government repeatedly says that it is interested in anything that will enhance the safety case. More mindless ramblings.. Mike
facthunter Posted June 29, 2007 Posted June 29, 2007 Reports. Mike ,don't feel too bad, we hear you. I don't see how we will alter the situation Re. the police & the coroner, However where Technical matters are a large part of the consideration, one would have to ask Are the police and the Coroner qualified in this area? Probably not . SO.. One would hope that there is an opportunity for suitably qualified people to provide the necessary input. I think our people went north recently for such a purpose. All well & good ,but as we are noticing, there is a long delay, (perhaps years) under this process. It would be hard to justify a situation where we cannot take action to inform our members of matters which affect their lives, because of the restrictions imposed by the structure. I have always been of the belief that if it is important enough, then a way must be found to get it done. I also don't believe that the views expressed on this thread imply any massive criticism of the exec.or the board , but it could be used as an index of our concern, and perhaps some of the better ideas might be some guidance..N
Guest TOSGcentral Posted June 29, 2007 Posted June 29, 2007 I do not think anyone need be concerned about the police and coroner. This is one that is continually trotted out, usually by people who do not want to grasp the nettle. Detailed accident reports two years down the track are not much use today! As has been continually been demonstrated over decades - it is quite legal and practical to put out a 'notification report' quite quickly, deidentified, and just stating what has happened - not necessarily why it happened. Bear in mind that of considerable use in trend investigation is the minor accidents, incidents and defect reports because they could be a fatal in the making. If you think you are muzzled on the big ones then the small ones tend to go with them as well, so we all stay in the dark. I have a larger overview post I hope to get out later today which may suggest where the real cause of the problem is. Tony
Guest Juliette Lima Posted June 29, 2007 Posted June 29, 2007 Hi All, Mike is right....this is about the future....this is about a constructive contribution to RA-Aus....this is about a strategy relating to safety...(which incidently should be part of the overall RA-Aus Strategic Plan)....this is about responding to the President's request for membership feedback.....this could even be about democracy. Cheers JL
Yenn Posted June 30, 2007 Posted June 30, 2007 If a quick review of all accidents is what you want, let us start here. If anyone of us gets involved in an incident or accident, I suggest it is posted here for all to see. Lead by example!
bushpilot Posted June 30, 2007 Posted June 30, 2007 If a quick review of all accidents is what you want, let us start here. If anyone of us gets involved in an incident or accident, I suggest it is posted here for all to see. Lead by example! I agree 100% with this; why dont we all use a specific thread where we post reports of any incident for others to learn from.. 5 years ago I crashed a nanolight and put myself in hospital for a week -and took 2 years to fully recover. A CFI was present at the time, and saw the incident; yet neither of us bothered to log a report with anyone. On reflection now, lots of pilots could have benefitted from my report - but there was no clearly defined structure in place to report it... And I figured at the time that my job was to focus on repairing my body - and if it had have been important to report the incident, then the CFI would have initiated that, or at least suggested it to me.. I'm not trying to dodge my responsibility, just saying that the 'system' needs to support and encourage full disclosure... This Forum is invaluable in that context - as someone else has said. Cheers, Chris
Guest Juliette Lima Posted June 30, 2007 Posted June 30, 2007 Hi again, We have come a long way with these discussions with some great contributions (hanging out for Tony's promised post)....so where to now? Perlorus32 is suggesting a review by the RA-Aus to develop strategies to enhance safety for our rapidly growing organisation. Some have suggested 'among other things'. If this work is currently being undertaken by RA-Aus then perhaps we can ask our Representatives to articulate the review terms. If not, then perhaps we need to ask our Representatives, is the association ahead of the boom in membership with a plan for the future, or have they been caught off guard....if so, then this would be perfectly understandable as 'should haves' are great with the advantage of hindsight. I do know there are individual Board members working hard on specific tasks however would like to know if they (the tasks) are part of an overall Strategic Plan that the RA-Aus may have already formulated to serve the future needs of the (close to) 8000 members.....and if so what is the plan? So Mike, how best to ask the questions without implied criticism and further, to offer the suggestions contained in your very constructive posts?....after all, the President has asked for membership involvement. It would be great if some Board members were actually reading the foregoing issues and concerns raised by many contributors..... Overwhelming response. The suggestion for a specific thread to detail our incidents in the interests of safety is also helpful....Ian recently got the ball rolling with some frankly expressed issues encountered during one of his flights.....these were well received by forum members. Cheers JL
rick-p Posted June 30, 2007 Posted June 30, 2007 I would like to put my two bob's worth in here as I have read all the posts in this thread and although interesting basically in my view for the most part what has been opined is nothing more than conjecture based on a knee jerk reaction to a situation that is no different statistically to that of probably 15 years ago, in fact it may even be better now than it then was. I think that the guys most on point here were Terry, Tony and David. Regulating further is not the answer, disemination of worthwhile information to those who want to hear it, take it on board and use that extra knowledge to fly safer is a step in the right direction. When you go solo or get your pilot certificate you really don't know too much and the real learning as to what it is all about begins when you can get out and away on your own and practice because that's what it's all about and never stop asking questions of those with the experiance and knowledge and keep reading those aviation mag's and books. Finally, you will never break free of the Richard Cranium's they are ever present and no amount of training or education will save them from themselves. Look at the gun laws they have stopped nothing, but unfortunately governments will never learn. I do a lot of ultralight flying in a country where there are basically no regulations, lots of mountains etc., and at one stage for a long time only a 300ft (I think) ceiling and to the best of my knowledge there has only been 2 deaths in 15 years. As for the post, I just can't remember who said it, "maybe it's something to do with age",young people adapt more quickly and react quicker than the older person who learns to fly later in life." Well what can this old fart say? My reply to that is, if it is being said that this may be related to the increase in the number of accidents, what a crock. I'm sure Middo would be impressed. I would have thought that the mature aged pilot statistacally would be more cautious and conservative than the young bullet proof Jet Jackson. I will leave it at that as I probably have raised more than just a few eye brows, but that's just my two bob's worth for what it's worth. Rick-p :devil:
Admin Posted June 30, 2007 Posted June 30, 2007 The suggestion for a specific thread to detail our incidents in the interests of safety is also helpful....JL There is a specific forum here called Incidents and Accidents which gives the opportunity for everyone to post about any incident or accident that they may have. The good thing about that forum is that firstly Guests i.e. any non-forum member can read them to help them to learn from others experiences and secondly you can post in that forum anonymously as a guest by first logging out of the forums, make a post in that forum - it will just show that it is made by a guest and not your forum user name, and then log back into the forums. The more we can learn from others experiences "FIRST HAND" and not hearsay the more we have in our ability to fly safer.
Guest Rocko Posted June 30, 2007 Posted June 30, 2007 Show us the money! I'm reading a lot of posts on this topic about analysis of figures, statistics, human factors, and how things "probably" haven't changed in 15 years. That's really good to hear. But... Lets see some statistics then? Who's analysed the figures? How far do the figures go back? Exactly what sort of information do they contain? Who's monitoring the trends? I'm sure someone who's posted on here has the information, or knows where to get it. Post it up so we can all take a look at it, so we can have hard facts to show other people that we are, in fact, "safe". Scott
Guest brentc Posted July 1, 2007 Posted July 1, 2007 I've now posted twice on how to get the information. I am willing to assist in obtaining it and analysing and or assisting with it's analysis. Those that wish to view the information must be RA-Aus members and available to view it. I already have one or perhaps two volunteers to assist, so if you are keen to help let me know.
Guest TOSGcentral Posted July 1, 2007 Posted July 1, 2007 In Search of Causes - Pt 1 I suppose this will be another long post, and in following parts to get it on the forum. I am going to attempt to cover a lot of ground but at the same time keep it coherent. It is more of a summary in an attempt to clarify where a valid starting point could be. I now intend to air a totally different track and perspective to the situation – what exactly is the root cause? Andy@Gawler (plus a few others moving in the same direction) wisely say that before trying to fix a problem then identify what the problem actually is. Suggestions coming forward are to analyse accident trend data etc to identify the nature of the problem - where it is coming from. That is fine, but suppose the actual problem is not where it appears to be but resides somewhere else and the accident trend is just a consequence of that central cause? What if the central cause is so large and seemingly abstract that it appears too daunting to be able to tackle effectively and the natural human reaction is to go for 'band aid surgery' rather than fixing it at source? The latest posts by Pelorus are moving onto that form of thinking. On the face of it we have an unacceptable amount of accidents and deaths. If we do not control this, or more accurately are perceived by the Regulator as controlling it and that we are capable of doing so, then external control will be exerted on us and at the minimum we will lose freedoms we hold dear and at the worse could lose effective control of our overall movement as we want it - whatever we fly. I personally do not feel we are too far away from that point at the moment. So let us pick up on some of the points in posts made above and see how they fit into a different perspective of the situation. To start with this is NOT an 'RAAus Bashing' session! But we are all bloody idiots if we do not take note of actually what happens rather than what we assume should happen and therefore does/will happen. Equally, it is NOT us and them - it is ALL of us that are contributing to the problem! I am not saying that individual pilots are deliberately rushing out to kill themselves (and others), nor that the Board/Managers are not fully supportive ethically of the survival of this movement. But is not working sportsfans and it has never really worked! The real seat of the problem resides in our attitudes which are dictated by our culture. Here are some real life examples - not hypotheticals! We will kick off with a remark, made almost in passing, in one of the posts above "(that solution) would not be popular". That is virtually the main manifestation of the real problem in a nutshell - tight, focused and much more powerful than many of us imagine! 1. There are several aspects to this: RAAus has been engaged in a major promotion campaign for several years to translate a simple ultralight movement into the bottom end of GA. That has been wildly successful and part of the promotion was to put our magazine on the public newsstands. It is a contradiction in terms to have a promotional device saying how wonderful it all is in conjunction with several pages of sobering accidents and incidents demonstrating the other side of the coin! So a central point - accident reporting from which trend information could be derived is minimised at source. 2. So we have to assume that there is little there to report on or draw trends from? If there is more there then that is a political and control embarrassment because why are the membership not being informed? 3. The membership do not help because they do not report enough! This may have several causal reasons but a clear one is that RAAus has pursued a policy of keeping centralised control in Canberra and distancing the membership from this. Members do not interact with an organisation that appears to see them as a customer - not a part owner of their own movement in practical terms. This is not opinion! It is common talk around the airfields and, as the driving force of the TOSG support group, I see far more accident and incident reports on the Thrusters than RAAus ever do. I get them because I do something with them and do that quite quickly, so my members perceive benefit in telling me. Some of those reports have been most serious indeed! 4. Assuming there were either full reporting or even substantial reporting, then how much trend information do you expect? We have a small handful of people actually running RAAus and there are only so many hours in the day. Trend reporting has been requested for years and it has never happened - yet it is a common and obvious part of an aviation culture that values flight safety. So you are not simply asking for data (that may not be anyway there) nor people to abruptly sort and analyse years of reports if they are there - you are actually asking for a change on the part of our controllers in their attitude to what is acceptable and to also find the resources to do the work. 4. Add to the above that for most of the members they do not give a damn about RAAus anyway! The organisation is merely a means of obtaining legal permission to do what they want, when they want, in a situation not dissimilar to the Department of Transport issuing driving licenses but lacking the Police Force to enforce the law! Member attitude to their Movement is a critical foundation part of obtaining a Safety Culture. Their disinclination to apply self-discipline is a product of the existing culture. It does not have as much to do with the quality of the flying schools as it does the obvious fact that once trained the member has no need to interface with RAAus again, except via the BFR, other than remaining financial. The impact of initial training fades and there is NO support training at Regional level to lure and maintain interests in self improvement. What percentage of drivers feel compelled to do advanced driving courses? What they already do is good enough for them. But what is the accident rate on the roads? 5. What also does not help is the situation of the members’ perception of what the movement controllers should be doing, but what they actually do. In accident reporting terms this is a major factor in how far things go. RAAus appears to be a controller but in fact is a toothless tiger and this is by choice, not situation! GFA are on a very similar basis to ourselves but they rapidly adopted a good set of fangs to go with their responsibilities – and are not backward in using them! The GFA membership do not (in the main) see this as onerous as they are well aware that such use is to the benefit of all of them. If one of their membership kicks over the traces to the detriment of the good name or freedoms of their movement then they expect the GFA controllers to do something effective about it – and damn fast! GFA constantly works on ensuring that CASA are confident that GFA has all of it’s control functions more than adequately controlling! On the other hand RAAus adopt a different line in practical terms as much as this does not appear to be the case on the surface. Outwardly RAAus projects an image of being THE controller of ultralighting, looking after the whole deal. But when pressed by circumstances something else happens. Certainly RAAus do discipline some members – generally the small fry but RAAus is pertrified of being sued! Avoiding this is not bad management because of the expense of legals and our poor cash reserves but it allows the larger fish to escape – and they are the ones doing the real damage because they are in positions of member influence and the members see what they are allowed to get away with. This is a very powerful ‘reversed peer group’ pressure particularly if the errant member has a steady flow of students through his/her hands and thus influences them at their formative stage. It has been said to me often enough from the very top of RAAus that CASA is the Regulator and RAAus can do nothing in terms of taking anyone to court. Sure, but that does not mean doing nothing! So let us look at what is actually done. (Continued in Part 2)
Guest TOSGcentral Posted July 1, 2007 Posted July 1, 2007 In Search of Causes - Pt 2 (Continued from Part 1) Consider some examples from the last few years, and you may reflect on how these have contributed to the lack of a safety culture that the present unacceptable accident rate is springing from (a) I was called as an expert witness to a court prosecution by CASA of an RAAus pilot who was conducting illegal (and advertising it) passenger carrying for hire and reward. During the course of this he crashed the aircraft into the sea and came close to killing himself, three other people and sinking a boat. The RAAus technical witness gave incorrect evidence, that the defendants enjoyed immensely and then made hay with, plus, the senior RAAus witness privately wrung his hands and said this should not be happening as the defendant was “one of our own and did much to promote ultralighting in the communityâ€Â. Personally I felt that RAAus should be heading a lynching party. I had no scruples about what I did over those two days! Perhaps of more significance was the only notification the membership got was a single sentence in a CEO report and none of you ever read an accident report about it – did you? Yet (suitably de-identified) that could have been a salutary article in the magazine regarding the consequences of illegal ultralight use and a pilot flying way beyond his capabilities. That is an attitude cause folks, not training. It is only something that your culture can at least minimize! (b) A Pilot Examiner, CFI, L2, owner/operator of a flying school was hauled to court by CASA on over 20 breaches of the Air Navigation Orders. He was convicted and jailed. RAAus did remove his formal ratings but they left his membership and pilot certificate intact. They only did the removal because I personally forced the situation through the Board who were most reluctant to grasp the nettle. I then acted as chairman of the Disciplinary Panel, allowed for such cases under the Constitution and myself and three other Pilot Examiners plus another Board Member unanimously recommended his total expulsion. The local ultralight members were appalled he was left a member because they were the people this guy had also ripped off and they had to force a separate criminal action to get their property back. No credence in RAAus left at that airfield any longer! In comparison, the same person once had similar authority levels in GFA and very similar charges brought against him (another 20 odd) a few years previously. When he was convicted Mike Valentine suspended him instantly and with Executive authority immediately kicked him totally out of the GFA (which is why we got him). © A South East Queensland school had a poor trot. This involved multiple write-offs of training aircraft, shonky ‘syndicate’ arrangements, and woeful airworthiness practice that was sufficiently bad that the local LAMEs on the airfield were totally disgusted and threatening mass ‘dobbings’. Despite written and verbal complaints to RAAus, nothing much was done, there were clear trends of a type specific accident area but nothing was done and few accident reports - and the situation continued. It was only resolved when offended RAAus members took the offender behind a hangar and gave him a thorough flogging! Not much credence in RAAus left at that airfield either – but plenty of ultralights! (d) A person who was a Pilot Examiner, CFI, and L2 (who RAAus had been waiting for a long time to get something really tangible on) was convicted and jailed under civil law via prosecution stemming from CASA over criminal misuse of an ultralight. That was clear enough for an automatic Disciplinary Panel to remove him from RAAus. But concurrently, written evidence was provided to RAAus of gross airworthiness negligence and falsification of formal RAAus documentation that was actually life threatening. Also concurrent was a written plea(s) from a new RAAus member for information on what RAAus where going to do about the situation as she needed to take legal action to recoup her losses that had nearly wiped her out under the hands of this person. 2.5 years later she is still waiting to hear back with any resolution she can productively use and as far as I know he still holds his ratings and membership. Did any of you know about this appalling situation? (e) A while ago I grounded an ultralight for technical reasons (with the enthusiastic support of the owner). When I discussed the situation with RAAus the problem with the aircraft was ignored and I was firmly attacked on the basis that I had neither power nor right to interfere with another member and his aircraft – not that the aircraft could easily have killed the inexperienced pilot! (That person was not the Tech Manager by the way). Now Sportsfans, does any of the above lead you to consider that we have a flight safety orientated culture that we can build on and promote? If we cannot hack it at the sharp end then there is no hope for the low end! Is any of the above ‘RAAus knocking’ or merely reporting of what has been done and the way things are done? Can we build a future flight safety culture upon that? While I may not agree with RAAus management methodology, in charity I would have to assume there may be good reasons for stances taken to situations that cannot be made public. I am not suggesting the situation is based on incompetence or neglect – it is just the chosen way of doing things. But is that a good basis for a progressive way forward? Now, a few posts have stated that we should leave things to the Board as they know better and will work in our best interests – How? Let us be practical please! Getting on the Board does not instantly transform you into Superman and the holder of all wisdom and knowledge. The Board is voted in on political popularity (or too often the person prepared to put a hand up). It is not voted in on demonstrated technical merit! So why should any such person be automatically assumed to be capable of informed and effective accident investigation and formulating trend data in useful terms – either as an individual or as a voting block that determines policy? Let us go a step further and ask a simple question. There are in fact a lot of Board members (13), but apart from the Executive what do they do? Why is one of them not appointed as specifically the Association’s Flight Safety Officer not as a title but as an active task? Go another step further – why should that person not then be empowered to assemble a standing task force from the general membership who have the skills, would be prepared to participate, but would not wish to be involved as a full Board Member? In itself this would alleviate load on overworked Managers. Go a bit further – why not also have specific Airspace, Public Relations and Information Technology officers? The nature of a structure moving into specific tasking in turn changes our culture into one that may be more practically attuned to flight safety needs. At this time of an escalating accident rate, rather than say “Oh, the Board will fix that†we would have a mechanism in place that we could immediately turn to. In fact that mechanism would have automatically already started working on the problem. In comparison the Board may have to wait six months before the issue is addressed and if it is ‘too hard’ another six months may slip by. How have we reacted in the past? A couple of years ago we had another nasty spate of fatals that were drawing outside attention to our control ability. There was an abrupt two part reaction revolving around ‘advanced pilot certificates’ and a restructure of the BFR where all the PEs and CFIs were circulated for input – and we got some good suggestions. But none of that actually went anywhere and as the flap abated so no steps forward were taken. It appears to have been an exercise in ‘RAAus is doing something’ when in practical terms it did nothing. (Continued in Part 3)
Guest TOSGcentral Posted July 1, 2007 Posted July 1, 2007 In Search of Causes - Pt 3 (Contnued from Part 2) To begin drawing this post into a circle: Earlier I put emphasis on a previous post that said ‘would not be acceptable to the membership’. This is where we really start seeing it. An organization pushing for member intake wants to keep them happy. Putting extra stricture upon them does not do that. But it is not just RAAus itself reacting to that area, it can be the members themselves! I will tell you a story. When I was on the Board I was called to a main meeting of the Queensland Ultralight Association who wanted to question me on my then current project of tinkering with re-issuing lapsed registration numbers to give a bit more status to aircraft that were part of the movement’s historical heritage. They did not like what I was doing and instructed me to desist – which I agreed to do. While I had the floor I passed by them a suggestion that we incorporate, as a formal and mandatory part of the basic flying training, a requirement that students be given basic airworthiness training that they were then examined on, as we had, and currently do not have, ANY airworthiness training at all! Present at that meeting were two ex Presidents of AUF, the (then) current President, and two senior QUA members who were later to become Board members. It was those five who led the attack against my proposal and ridiculed it on the basis that we were a ‘freedom association and any forms of control were not good for the membership and would be rejected by them’. I replied that I was talking only of giving the basic understandings and knowledge to adequately pre-flight an aircraft. In return I was informed that the membership would not understand such technicality and that it would be an unacceptable imposition on them! So that appraisal came from the membership – not the Board per se! My only solace from that meeting came from a few members that followed me out who were run of the mill inexperienced pilots, not politicians. They thanked me for trying and asked that I just hang in there – for them! Of additional interest may be that most of that detracting crew also one day stood on an airfield and applauded a pilot wringing out a Lighwing in aerobatics. They later denied they witnessed anything and blamed myself for ‘dobbing them in’ for not reporting it. As it happened I had not done so! But later that pilot came to me for a jump start and I discovered that his engine had not had the plugs replaced since new – 200 hours – let alone gapped and cleaned. He opined that may be the reason he had been into half a dozen paddocks on forced landings during the last month! A couple of weeks later he was back. He lost a blade off the prop (that he confessed he knew was cracked but ‘was watching’)! Unfortunately the engine also came off it’s mounts and the only thing that saved him and his innocent passenger was that the cowlings and control cables kept the engine on board for the forced landing. Not satisfied with that, somewhat later he totally destroyed his new aircraft in illegal low level aerobatics and rendered himself never capable of flying again. He is not quite a vegetable but not far off it! There were no accident or incident reports for any of the above. The next stage I wish to come to is answering the comments and statements given of ‘take it to the Board – they will fix it’. Really? Been there and done that! Back in the early 1990s I took a paper to the Board and presented it personally. The time seemed right as the ‘Old Guard’ had just had a political coup imposed on them by the ‘New Guard’ who were going to fix all of the problems. I simply suggested a paper on what GFA were so adequately demonstrating worked so well and that we should get back to Regional effective control, utilize the membership resources we had and build a workable management system. I was received politely enough but it was all discarded and went no further. The Board at that time were dead set on centralized Board Control in Canberra with a couple of managers – they actually built the bottle neck we now have and did so deliberately. So, later I joined the Board and found out what was then going on. I fought the member disinformation and the Board disinformation (or no information) and I did so virtually single handedly. I tried to protect individual Board members who were attacked and annexed, or forced into resignation because they were not toeing the line and were asking their own ‘sensitive’ questions. I eventually resigned in disgust because I could do no more. Sometime later I tried again. I circulated a paper to my three Regional Reps and a couple of other Board members, on just basic aviation management planning of our Association in the manner of questions on what the Board were doing – to be put on the Board agenda. I did not even get an acknowledgement of receipt, let alone a response. I did pick up some information and that was that it was ‘under consideration’. That was two years ago! So I am afraid it is a bit trite to expound about ‘Board Strategic Plans’ for the movement because I doubt any such thing exists. If it did then we would know about it and after 20 odd years that is a reasonable statement to make! Finally, several pleas have been made on how could we make it better rather than quacking about what is wrong. I have already put in my views (in reasonable detail) on the RAAus forum on this site. Interestingly there has been only one response – from Yenn – who said take it to the Board. So perhaps I will – again – but I think I am persona non grata as I ask the wrong questions and deal with things as they actually are – not what we would all like to assume they are. OK, where are we at? I want to pull this all together now. I am sorry it has taken so much reading but it really is a complex subject with so many different points of influence. I do wish to emphasis that all of the information given above is true, can be substantiated from multiple sources and is no form of ‘hypothetical’ view point to advance an argument. That is what we actually have so let us deal with that as it is! Our main issue in this thread is “what to do about an unacceptable accident rate†especially as it is damaging to us in both political and control integrity terms. Wise comment has been given already by others that we look at causes rather than outcomes – I am just going a few steps further. I suggest, that in an overview situation, we are going to go nowhere with detailed accident reports that we will have to wait a long time for, if we ever get them. I do not believe a rapid solution will be found in accident trends because I know there is insufficient information to give an accurate overall trend. The most expert team available can do nothing without responsible data. I do not believe the main causal reason is lack of training or simply flaws in the system (although we have plenty of those starting with complete absence in some areas after 20 years). There is a discernable trend though and that is the attitude of the pilots that led them to kill themselves and anyone with them. We are always going to have the lunatic fringe and will never have a perfect accident record. But that fact of human nature does not have to spill over to rational people! That is happening and it can be controlled! The control may more productively come from not the accidents themselves and working backwards to see what causes them as individual events, but from an overview perspective that identifies the reasons for the attitudes in the pilots that caused the events and therefore working forwards in building a new tomorrow in which there is less chance of such events. That comes from movement structure which then creates the culture that we have. If that structure is pro-active, close and supporting to the membership, leading by example – then we will get a safety orientated culture and the members will go along with it well enough. That cannot happen quickly, so I suggest we scare the living crap out of current members, via powerful magazine articles, to get them back into line long enough for that new structure to be built! There is nothing new in any of this. We get these accident spates and members realize that it maybe could happen to them so quieten down a bit until all feels secure – then it starts again. Sorry Sportsfans a long and probably tedious post. Those are my views – what are yours? Aye Tony
Guest micgrace Posted July 1, 2007 Posted July 1, 2007 Hi Tony I notice one good idea that may be of use. Incorporation of basic airworthiness course into the original pilot certificate and as part of a test. Whether that ever happens is another matter entirely, but would be an excellent start. Micgrace
Guest Rocko Posted July 2, 2007 Posted July 2, 2007 Congrats... Thank you, Tony. That was beautifully summed up. Scotty
Yenn Posted July 2, 2007 Posted July 2, 2007 My third attempt to respond to Tony's post. It seems I was naieve to think that our board is doing all it can to keep us safe. I was also involved in a court case where a member was convicted of dangerous low flying, and I am told that he is still a member. If the situation is as you say Tony I think it is time for us as individual members to start questioning the board, to find out what is the actual accident situation and what is causing incidents and accidents. I can see that with our magazine going on the newsstands that there may be a perception of hushing up bad publicity, but I for one want to know all I can about anything that can impact on my safety. Thank you Tony for your post.
Guest Flyer40 Posted July 2, 2007 Posted July 2, 2007 Behaviour based safety Tony It's reassuring to see so many people contributing so fully to this discussion. Your conclusions are very insightful and I'd like to add to a few of your points and put a few idea's out there for discussion. But first I'll say straight up that the following is a bunch of generalisations to stimulate discussion and in no way represents any kind of analysis or conclusion on specific incidents or accidents. Accident rates rarely follow the standard distribution. These seemingly inexplicable spates of accidents happen in all industries from time to time. We can all recall this happening with the road death toll. In another example there is a segment in one industry with an employee fatality rate of 0.8 p/year, resulting from 5 fatalities in 1998 and none since. You are absolutely correct in saying that accident investigations look backwards, and by inference, good risk management is about looking forward. Further, due to the lead-time involved, accident statistics and trends do not usually provide real-time data and it's possible that the causes will have self corrected by the time a detailed trend analysis becomes available. All true. However, a whole lot of learning and prevention arises from the work of investigators and their findings are vital to making informed decisions about risk management. People often call for more training as a solution to a problem. It's sometimes referred to as "blame and train". However it's worth remembering that training is usually only useful in solving a problem where a systemic knowledge deficiency has been identified as the cause of errors. Which leads into my main point: Training is rarely a solution to poor decision making, where that decision making is reflective of the culture or individual behaviour. I had a huge rant here about culture which I deleted and will simply say that when the effects of poor decision making are being seen across an entire population, the culture really needs to be examined. So if culture is what influences risk tolerability and decision making as a group, then the outliers must represent the individual departures from the norm. And I think this leads into a discussion about freedoms. We all recognise that we are really only here for the freedom and enjoyment that we derive from recreational aviation. But the very nature of human variability means that some people are more free spirited than others, to the extent that their personality may put them on the wrong side of the risk tolerability equation. None of us want to see a reduction in our freedoms. Indeed many of us are here because the needless over-regulation of GA has taken the fun out of it. But CASA has the power to remove or restrict those freedoms if they loose confidence in your ability to self regulate. So after all that rambling, I seem to have given a bunch of problems without solutions, well at least not directly. That's because there aren't any silver bullet solutions. Some might say the leaders face a significant challenge in balancing freedom and regulation and keeping everyone happy. But they'd only be half right, because the accident statistics and the reputation of the organisation in the eyes of the general public and media is a direct consequence of the behaviour of individual pilots. Maybe I'll title my next submission "so you think no one is watching and you wont get caught? well camera phones are everywhere and have I got a photo to show you!" Mal
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