Guest Redair Posted July 2, 2007 Posted July 2, 2007 Hard nut to crack Tony, I think you may well have hit the nail on the head there, when you say that it is all about peoples' attitudes. From the top to the bottom, Board to Pilots, there are always going to be those who do not believe the rules apply to them, and there are going to be those who do not like to be questioned. The "I'm going to do what I want" attitude is rife, not just in ultralight circles, but throughout life in general. I witnessed an example of this kind of attitude just recently, (nothing to do with flying I might add) whilst attending a course, where at the end of each session/lecture, and assesment book was required to be completed, to see if everyone had graspped all the required knowledge. This was fine until one of the others on the course started to fill in his assesment book, as the lecture was proceeding. A senior lecturer noticed this and asked him to stop, and pay attention to the lecture. Fine again, until the next session began, and the "I'm going to do what I want" syndrome took hold of this chap once again, as he reverted to filling in the book as the lecture went on... and as if this wasn't bad enough, (and perhaps something that may well be happening in the ultralight world) one of the other people on the course decided that if this guy could do what he wanted, then HE would do it too. I think that it is going to be an uphill battle to stop the idiots from doing their own thing, and an even bigger one to stop the sheep that seemingly love to follow the bad example set by others. That together with those who either cannot or will not get involved in putting a stop to this kind of behaviour, will result in a long slow process to put right what is going wrong in the ultralight area of the skies. I agree that not all accidents are the result of shear stupididty or risk taking, but at least if this area of the total crash figures could be targeted, maybe the remaining nuber of TRUE accidents would not seem so unreasonably high. Redair.
vk3auu Posted July 2, 2007 Posted July 2, 2007 Tony, you have articulated many of my concerns about the reporting and publication of accidents. A couple of years ago at Narromine I was eavesdropping on a conversation regarding a recent non fatal accident which had resulted in major damage to a popular make of aeroplane, enhanced by what seemed to be a major manufacturing defect. I waited for a report of that accident to appear in the magazine, it never did. I have my own suspicions as to why, but an AD should have been raised and it never has either. Let us hope that a new culture is born with the advent of a new Executive Director. David
cazza Posted July 2, 2007 Posted July 2, 2007 Tony and others who have contributed to this thread. Firstly I am pleased that safety as an issue of concern to all pilots has had such a thorough discussion. I have noticed many good ideas for improving safety and I also have been given a background of the difficulty of actually effecting change in an organisation that fights daily for respect in the aviation industry and fights daily to keep its priviliedges . Tony's posting was very illuminating. You all know what the organisation (primarily Lee and Mick) are doing to improve safety. 1. Revised operations manual with more emphasis on learning skills through a performance based objective approach; 2. Inclusion of General Pilot Proficiency Program content into training of student pilots and instructors. This program seeks to improve safety by tackling the biggest reason pilots kill themselves and others….human error; 3. Provision of workshops training members in the GPPP; 4. Cyclical inspection of Flight training facilities to identify practices that need to be adopted or changed and in-house professional development of instructors as a result; 5. Instructor forums at Natfly; 6. Articles in the magazine targeting issues of safety; 7. Encouraging members to take responsibility for safety at their aerodromes and to use peer pressure to ensure safe practices by all; 8. Publication of ADs and other notifications of technical problems. 9. Reports of accidents in the magazine when permitted by the Coroner. But as Tony and others have pointed out, bad decision making, the unrealistic attitude that 'the bad things that happen to others won't happen to me' syndrome is the major cause for FATAL accidents. Lee and Mick are working on this through the GPPP program, but your discussion has made me realise that there are many more avenues to explore and try. So keep talking. I am a researcher by trade and the skills I bring to this organisation include identifying major ideas, collating ideas and synthesizing ideas from this forum for improving safety. I give you this guarantee that I will use this discussion and the information I get from ATSB and the available accident information sources to produce a set of recommendations to improve safety. I will post it on this forum so that you can see the results of your deliberations and I will keep you in the loop. CAZZA
Guest Juliette Lima Posted July 3, 2007 Posted July 3, 2007 Hi Carol, Thanks for reminding us of the good being done by RAAus regarding safety. Tony's post has left a decidely bad taste in respect of some RAAus individuals in particular the " powerful reserved peer group". I know five current Board members and have had training flights with three of them. I have little doubt that their own integrity, and their schools safety standards, are of the highest and most demanding levels.... certianly akin to the the GFA experience. It would be extremely disappointing to me and to many of their former students to learn that these individuals might be part of the peer group Tony refers to....I doubt it anyway. There is probably nothing we can do about the individuals with an indifferent attitude to safety. These people also existed in gliding....I once found myself in a 50% partnership owning a beautiful 17 metre glider with a person whose 'gung ho' atitude became apparent subsequent to the puchase.....I quickly offered him my share which he accepted......sadly he killed himself at Narromine afew months later. Correct, there are individuals we can't help, and there are many who don't give a fig about the RAAus....but there are a substantial number of us who DO CARE about the Association, a culture that values safety, and its public perception. Tonys suggestions that basic airworthiness be part of a training program is hardly an imposition on our basic freedoms.....it's essential to us staying alive. (To those who are interested, check out his excellent article on airmanship under training on the RAAus website...essential reading) Suggestions for an Association Flight Safety Officer(Board member) complimented by a member Taskforce, and further, other specific tasked officers with empowerment to assemble working parties, seems to be worthy of genuine consideration by the Board. As far as not wishing to mix 'Marketing the Association' with the reality of reporting fatal accidents in the RAAus mag... what about "scaring the living crap" (Tonys words) out of members by forwarding a seperate publication to members which would not be included in the newsagency issues. It need not be expensive, and the resolve to do so might well be included in the Association's Strategic Plan....speaking of which, No one would fly say from Cessnock to Temora (or any cross country journey) without a considered flight plan.....why then should an 8000 strong member organisation not have a Strategic Plan. Every business worth its salt has a strategic plan. I would assume that any new Board member would automatically ask for the plan, and the Association's policies and procedures, upon being elected. I would also expect that the interviewing panel for the next CEO will ask the very odvious questions of those applying, as to their understanding of the process in developing a strategic plan....which would include in part, the safety issues raised in this forum..... that is if a plan does already not exist. Carol, thanks once again.....keep us informed and the best of luck. Cheers JL
Guest Andys@coffs Posted July 3, 2007 Posted July 3, 2007 People Tonys response certainly is a multifaceted piece of work. No doubt much thought went in to his posting and as such it deserves some reasonable consideration. One point that I picked up on is that Tony suggests that the RAA team is a toothless tiger when it comes to disciplinary needs. Yet I do know that the team does employ discipline, I’ve seen and requested information about it my self. The flying parachute display at Narromine this year was a case in point. I requested info about any discipline approach to that display and was told that it had been applied. So an idea that a supplement be added to the magazine post out for members that contains de personalised accident and incident information might also be supplemented by de personalised discipline applications. In providing this information we all might stand to learn from the accidents, and see the real consequences of ignoring the rules. In addition to providing information about completed cases, accidents and discipline, information about cases still under consideration needs to be provided as well. Obviously only to the level that is consistent with the progress that has been made, and never more than the known facts. Lastly I’m acutely aware that I’m offering solutions to a problem that isn’t yet proven (in my mind) to exist and as such I’m doing what I asked everyone else to not do, that being jumping to a solution. In this case I can’t see any detrimental aspects to the provision of this information, indeed if anything it helps protect us from the claims that we do not have an appropriate safety culture. As a parent, I know that my children need to understand the boundaries, and the consequences for operating outside of them. Its simple human nature and as flyers we all need to know the same information. Consequences are only something that we will consider if we know that they are applied. The facts that we are a low cost operation (which translates to low staff count) would suggest that the only way the board will become aware of people operating outside the boundaries, so that investigations can occur and consequences can be applied if appropriate, is if we tell them. In doing so you may act to save the life of the perpetrator, but in any event you are definitely acting to save the freedoms that we currently enjoy. Thoughts? Regards Andy
Guest Redair Posted July 3, 2007 Posted July 3, 2007 sugestions to help with educating pilots could be: 1. emailed accident reports from RAA to all members, including FULL details of how when what and where, (names do not have to be included of course) together with a clear "What not to do" section at the end to avoid the same situation. All for now, Redair. As far as not wishing to mix 'Marketing the Association' with the reality of reporting fatal accidents in the RAAus mag... what about "scaring the living crap" (Tonys words) out of members by forwarding a seperate publication to members which would not be included in the newsagency issues. It need not be expensive, and the resolve to do so might well be included in the Association's Strategic PlanCheers JL That was what I was on about when I made my earlier suggestion of direct emailing to memebers. Redair.
rick-p Posted July 3, 2007 Posted July 3, 2007 Tony, in a nut shell thats it, a bloody big one at that. I hope the appropriate people read your post. Regards, Rick ;)
Yenn Posted July 4, 2007 Posted July 4, 2007 Why hope that the appropriate people read the post. You could write or email to the appropriate people yourself. Don't live in hope that someone else will do it.
rick-p Posted July 4, 2007 Posted July 4, 2007 Ian that wasn't my point. I typed up a great long reply but my fat fingers at the end got in the way and backspaced it somehow which resulted in a total delete being effected. I will PM you my phone number in due course and if you like you can call and I will explain to you my observation. Maybe it was better that my reply was lost in cyberspace as it may have been offensive to some. Best regards, Rick
John Brandon Posted July 4, 2007 Posted July 4, 2007 One death or serious injury is one too many and particularly disheartening when so many are just repetitions of the same old pilot errors that have plagued GA and ultralight aviation for so many years. I hoped to get more interest from this forum a couple of months ago when I signalled my intention of producing a publication dealing with these ongoing fatal accident causes. Be that as it may the RA-Aus accident rate should also be compared with membership levels and with number of aircraft on the register. I have published the stats for 1985 - 2006 on the website notice board in the form of a bar chart supplied by the office. John Brandon
Guest Andys@coffs Posted July 4, 2007 Posted July 4, 2007 John Thanks for the graph, it is interesting. However can I ask a point of clarification the "Fatal Accidents" statistic that is shown, if an accident occurs that has a PIC and passeger killed will that show as 1 on your graph or 2. I pressume 1 but want it clarified. With regard to the publication that you are intending to produce, where will the information that it contains come from, and to whom will it be distributed. Is it being generated by you, as a member of RAA, or on behalf of the board of RAA? Lastly are you intending to explore any systemic issues, or will you limit your reporting to the individual known facts per instance? Reading between the lines of many of this threads postings, people are suggesting (through Gut feel rather than any analysis yet) that there are more systemic issues at work. Andy
Arnaud Posted July 5, 2007 Posted July 5, 2007 I am not happy... I just spent over an hour typing my contribution to this topic and when I clicked "Submit Reply" I was informed that I was not logged in. After again logging in my original message was gone ! It is not the first time it does that to me. Why is modern technology so user non-friendly ? I hate to waste valuable time so that was my last attempt at participation. From now on I will be a silent observer as no doubt the majority of us are. Arnaud PS: I will be in a better mood this afternoon as the weather looks ideal for a local flight in the 912XT
blueshed Posted July 5, 2007 Posted July 5, 2007 New Intructor Wow I have just read through this thread, being a new user to this site it has taken me a while to catch on to modern technology. As I have recently qualifed as an instructor and am increasing my instructor hours this thread is of great interest with some fantastic thought's and idea's. Coming originally from a small aeroclub with a gliding wing(which I was initially involved) the GFA actually then had a particular qualification for being able to do the Daily Inspection. Which ment you generally had to have passed some form of education on that particular type of craft. Airworthyness I imagine it to be! BFR, what should it contain? It, as I see it, is an oportunity to locate any habits which may be detramental to the safe operation of your machine. Does it also need to be a Biannual Brain Review? Was on the outside of a BFR the other week where the person who was due for thier Review arrived with thier aircraft, and expected the CFI to sign them out without even getting airborne, as they reckoned that the CFI had seen them go flying and they were flying in the vacinity of 200 hours/year. Maybe this is one of those attitudes which has been spoken about in this thread! Why are Airline pilots put in simulator's at regular intervals? I feel they probably do a few more hours/yr and have initially been trained to a very much higher standard. Safety as suggested in this thread starts with an attitude, one with which you are open and willing to learn, however this is also flanked be a box or a set of guidelines, rules and a general culture. This is important! The Culture! what is it? where does it come from? Most things Subtend from the uper level's. Once again Thanks Guy's and Gal's for a very interesting discussion. Much food for thought Cheers Guy
John Brandon Posted July 5, 2007 Posted July 5, 2007 JohnThanks for the graph, it is interesting. However can I ask a point of clarification the "Fatal Accidents" statistic that is shown, if an accident occurs that has a PIC and passeger killed will that show as 1 on your graph or 2. I pressume 1 but want it clarified. With regard to the publication that you are intending to produce, where will the information that it contains come from, and to whom will it be distributed. Is it being generated by you, as a member of RAA, or on behalf of the board of RAA? Lastly are you intending to explore any systemic issues, or will you limit your reporting to the individual known facts per instance? Reading between the lines of many of this threads postings, people are suggesting (through Gut feel rather than any analysis yet) that there are more systemic issues at work. Andy G'day Andy, Yes as stated on the notice the statistics follow the aviation convention; number of accidents involving a fatality not the number of fatalities; and of course the number of accidents where any POB received crippling injuries is not included. For information on the publication referred to see the thread titled 'Proposed safety publication' in the 'training and student pilots' forum, probably about March 2007. You ask whether the proposed publication will discuss systemic problems. My view is that a major systemic problem exists and it is the following: Most RA-Aus recreational pilots, as with most general aviation recreational pilots, accumulate only a few hours each year. About two thirds of recreational pilots fly less than 50 or 60 hours; perhaps such annual hours is enough to maintain physical flying skills learned at the flight school – if the pilot has established a program for self maintenance of that level of proficiency – but maybe not enough to maintain a high level of cognitive skills, for example situational awareness, judgement and action formulation. In addition, once having completed flight theory studies sufficient to pass the basic aeronautical knowledge test and achieve the Pilot Certificate, it seems that many, perhaps most, pilots leave it at that, failing to expand their knowledge by further in-depth studies of flight dynamics because it involves sometimes difficult detail rather than the broad brush approach of the flight school and perhaps assuming that such knowledge will be expanded through consequent flight experience. Assuming, I guess, that they will survive each experience. However many pilots are just continually repeating the same flight experience — each year is the same as the last — so all they accumulate is a repetition of one year's experience. They have no program of deliberately accumulating advanced skills nor have they really absorbed the safety basics which should have been drummed into them over the years — never turn back following EFATO; always maintain a safe airspeed; if the engine has been misbehaving never take-off until the problem is identified and fixed; if the engine goes sick in flight don't try to make it back to base, land it ASAP; don't continue into marginal conditions - turn back, and so on. Those causal factors mentioned were evident in the latest series of fatal accidents. So the systemic problem exists with the pilots; many are just not ensuring that they accumulate adequate post-Certificate knowledge and skills. In short they never really learn much about flight dynamics [and some of their accumulated beliefs are dangerously false] and they lack other pertinent knowledge and worse, they are just not listening or hearing. And of course at the other extreme we have the 10 000 hour pilot with all the experience in the world who destroys himself and his passenger near the top of the Great Dividing Range because he thought "I can make it!" John Brandon
BigPete Posted July 5, 2007 Posted July 5, 2007 Arnauld - we have all suffered the same fate! If you have something to say - and you did, use wordpad/notepad to compose your message, copy it and paste into the reply window. I'm sure we would all like to hear as many opinions as possible. I look forward to your contribution. regards
Yenn Posted July 5, 2007 Posted July 5, 2007 RickP. My comment about not waiting for someone to read this forum was not directed at you but to all members of the forum, especially those who have posted criticism or critical comments, and I have emailed our RAAus president, with my comments. A bit too soon to expect an answer, but I am sure it will be forthcoming.
Guest TOSGcentral Posted July 6, 2007 Posted July 6, 2007 Yeah! Well I have been out of this discussion for a few days because my 83 year old mother has had a double stroke after a failed major arterial operation and I have been (and will be for the next couple of weeks or so) very distracted with the consequences. Now, my following is mainly addressed to Cazza. Firstly, thank you for your encouraging reply post, but I wish to take you up on a few issues and I request YOU to reply to them on what YOU feel – not on the lines of ‘I will have to take that to the Board and see what they feel about it’. I am not trying to put you on the spot Carol but (along with Techman) we are getting some human direct contact with the Board/Management via these forums and that is healthy. But your response is (reasonably) what two guys in the office are doing and what comes out of NatFly forums (that most of us are not privy to). So I put to you the following questions: Do you believe personally that we would engender a better ‘safety culture’ if we were all working more together at member level? Do you accept that we already have a Pilot Examiner and L3 structure in place that is rendered toothless other than via direct charge via the Office to do something? What do you think about those appointed people getting together at Regional level (in their respective areas) and forming panels to work more face to face with the membership in example, support and local training? Do you believe that those (probably 50 guys) may be more effective and add practically to what the three guys in Canberra do? Do you believe that those people could elect one of their own, who would be an automatic Board representative, to feed the Board with actual real time perspective of what is going on at the workface? Do you believe that would be beneficial to flight safety and the good of the movement? Why do you believe that has not happened when it has been demonstrated to clearly to work by so many other disciplines for decades? That will do for now Carol and I would appreciate your straight response. As you probably gather I have no faith in the current control structure whatsoever and I am very anxious to find out what parameters they are actually working on – as the membership has not been informed of any Board management planning. Aye Tony
Yenn Posted July 6, 2007 Posted July 6, 2007 Have a look at the RAAus site. The bar chart of fatal accident statistics looks a lot better than this thread seems to indicate. Accident numbers down and membership up.
cazza Posted July 6, 2007 Posted July 6, 2007 Hi Tony, OK, here goes MY PERSONAL VIEWS> Do you believe personally that we would engender a better ‘safety culture’ if we were all working more together at member level? That is a no-brainer for me. I believe absolutely that the more people who work on improving safety, the better chance we have of improving it, especially the 'non-fatal' type, because the 'fatal' type seem to fall into the 'attitude of the pilot' area which is more difficult. But I also think that if new pilots were 'reared' in a safety culture with everyone working together and modelling good safe practices and using peer pressure and education it would make a difference to the fatals as well. Do you accept that we already have a Pilot Examiner and L3 structure in place that is rendered toothless other than via direct charge via the Office to do something? I think that PE's and L3's and L2's could be utilised more, be given more responsibility and be given training and support. And I think these people do the jobs for love and for the organisation. (I think the skills the Board members have could also be ultilised more to support the organisation). Some of us want to help, but if one is not on the Executive, it can be difficult unless you are doggedly determined) What do you think about those appointed people getting together at Regional level (in their respective areas) and forming panels to work more face to face with the membership in example, support and local training? That's a great idea. What about the organisation financing their travel to a location for training and support and professional input identified by them? What do they feel they need to do the job? Do you believe that those (probably 50 guys) may be more effective and add practically to what the three guys in Canberra do? The more the merrier. If a program were designed in collaboration with those guys and supported by the managers in Canberra, it would be a wonderful service to the organisation. Do you believe that those people could elect one of their own, who would be an automatic Board representative, to feed the Board with actual real time perspective of what is going on at the workface? Do you believe that would be beneficial to flight safety and the good of the movement? The concept is good. The constitution is the problem. We would have to change the constitution to allow this, which would mean getting someone to give up a state position on the board. You've been there, you know what that would be like. In the short term, however, why can't the Board coopt that elected person by the group to feed the Board with the actual perspectives of what is going on? I think it would be beneficial. Why do you believe that has not happened when it has been demonstrated to clearly to work by so many other disciplines for decades? This is pure speculation because I have no data on which to base any opinion. So here it goes: Perhaps it is because: Many board members are L2,or 3 and PE and they feel they adequately bring the concerns of that group to the Board. Many members of the organisation do not bring their concerns to the Board. Like any institution, it gets stuck in its own inertia and changes and new ideas are often (not always) looked upon with some suspicion. We've never done it that way, or we tried it once and it didn't work, or we've always done it this way seem to prevail. Remember, these are my opinions. CAZZA
John Brandon Posted July 6, 2007 Posted July 6, 2007 Have a look at the RAAus site. The bar chart of fatal accident statistics looks a lot better than this thread seems to indicate. Accident numbers down and membership up. That's not the point. If you extrapolate the figures you might surmise that there will be 6 fatal accidents in 2007 and perhaps the same in 2008. If you guess that a passenger will also die or suffer crippling injury in 50% of accidents then total casualties during the two years could be perhaps 20 persons. Such a casualty figure is horrific and particularly so when probably all due to pilot error resulting from a lack of pilot competency. What are you pilots, the members of this forum, doing to improve your competency? John Brandon
facthunter Posted July 6, 2007 Posted July 6, 2007 Response. What is pilot error supposed to mean? It's a term we see in the newspapers. We need to look a little deeper than that. The fact that many of us have put a lot of soul-searching into our words and seek better outcomes for the organisation must indicate that we are somewhere along the way to a better result. Do you want us to indicate what we as individual pilots are doing to achieve/ maintain competency. How would a low-hours pilot know what he lacks? Everyone here would like to see a better result .Some need guidance, and some can contribute, but we're not yet organised. Nev..
Guest TOSGcentral Posted July 6, 2007 Posted July 6, 2007 Cazza, Thank you sincerely for your candid reply - it is most welcome as it is encouraging. Aye Tony
Guest pelorus32 Posted July 6, 2007 Posted July 6, 2007 That's not the point. If you extrapolate the figures you might surmise that there will be 6 fatal accidents in 2007 and perhaps the same in 2008. If you guess that a passenger will also die or suffer crippling injury in 50% of accidents then total casualties during the two years could be perhaps 20 persons.Such a casualty figure is horrific and particularly so when probably all due to pilot error resulting from a lack of pilot competency. What are you pilots, the members of this forum, doing to improve your competency? John Brandon John, I think that is almost spot on John - even one death is unacceptable. The issue that this thread has been digging at is just what does "pilot error" mean? If I fail to get the stick forward during an EFATO and I stall and maybe spin then that's a S&R issue - one form of pilot error. If I persist in conducting aerobatics in an aircraft not designed or approved for that. If those aerobatics are contrary to regulation; then I am a violator. You could maybe fit me in the broad category of pilot error - albeit more active than the stall/spin situation. If I launch in marginal met conditions; persist as the conditions deteriorate; and ultimately if I am a victim of a CFIT; then that's something that I have been told about so often there is apparently no excuse. the fact that these accidents continue suggests that whilst it's pilot error it is probably much more complex and multi-faceted than the other two. I could go on. My real point is that "pilot error" is a very broad territory that doesn't actually help me in arriving at a resolution and resolving the distressing situation of even one death. At one point I am dealing with "simple" S&R failure - probably a skill failure. At other points of the picture I am dealing with quite complex human factors. At yet other points I'm dealing with a willful violation. Each requires a different response. At risk of pre-judging a recent accident, but equally sick of beating about the bush on this: Did the guy in Italy, the guy who specified he was about to conduct a pass in excess of Vne, did he do that in ignorance of the implications of exceeding Vne? Did he do it out of hubris? Did he do it in a false sense of the capabilities of the aircraft? He certainly did it with explicit disregard to the urgings of many people who knew and respected him and were worried about his behaviour. I am aware of no evidence that he had a death wish. Why did he do it? That's a complex question. There are also questions about the flutter performance of the aircraft, the structural integrity of the aircraft etc. A really multifaceted issue. Pilot error? That's too simple to help. I haven't even dealt with maintenance issues or what appears to me to be patterns of equipment failure with particular equipment. Yes even one is too many. No the responses are not simple and simply calling it pilot error doesn't advance our ability to respond. We need multi-faceted responses, I am sure there are no simple solutions. But above all I'm with you John, one is one too many. Kind regards Mike
Guest micgrace Posted July 6, 2007 Posted July 6, 2007 Hi Just a quick note. Vne is set at 0.9 of design Vd. which is set by various factors, the main, the g's developed pulling out of the dive. Technically possible to exceed Vne safely, but VERY HIGHLY DANGEROUS. Incidentally, it is possible to fly inverted with a nonsymmetrical airfoil, however, the inverted stall speed will be very much higher. The main trouble being lack of systems design to enable prolonged (more than couple secs) inversion. Micgrace
Yenn Posted July 7, 2007 Posted July 7, 2007 Surely pilot error is when a pilot stuffs up and as Mike points out that has many reasons. Usually we get the info about an accident and when it is put down to pilot error we can work it out for ourselves. In the same way mechanical failure can have many reasons. The use of these terms is only a quick way to give a brief overview and we need to read a full write up to really learn what happened.
Recommended Posts
Create an account or sign in to comment
You need to be a member in order to leave a comment
Create an account
Sign up for a new account in our community. It's easy!
Register a new accountSign in
Already have an account? Sign in here.
Sign In Now