Plane Crash North Stradbroke Island

[Teckair]

It is well documented that we have been making the same mistakes almost for as long as aviation has been around. Generally speaking, it happens when you were doing something that you were taught not to, and we're quite aware that you shouldn't be doing it.

I think anybody who says they are too good to learn from other peoples mistakes could be famous last words.

 

 

[alf jessup]

Obviously as humans we never learn from others mistakes as we keep on doing it, maybe we believe it won't happen to us as it only happens to someone else.

 

Not a good way to think is it.

 

 

[Nobody]

I think anybody who says they are too good to learn from other peoples mistakes could be famous last words.

I think that the issue is that many accident write up focus on what happened not why it happened. This is works well when the reason for the incident is a mechanical issue. When a pilot issue is identified then the focus on what happened leaves the reader thinking "I would never make that mistake, I am better than that guy."

 

Everyone has probably read a story of a case of VFR flight into inadvertent IMC. It is easy from the armchair to conclude that you wouldn't do it but people still do. They are not more reckless than others. Any write up of an incident involving poor pilot decision making needs to be read with the right mind set. The reader need to be constantly thinking at what point would I make a different decision.

 

 

[Teckair]

Obviously as humans we never learn from others mistakes as we keep on doing it, maybe we believe it won't happen to us as it only happens to someone else.Not a good way to think is it.

No it is not a good way to think but some of us do learn from other peoples mistakes. I have never attempted to fly in cloud why? Because other people already tryed it and it was no good. IFR excepted.

 

 

[M61A1]

I think that the issue is that many accident write up focus on what happened not why it happened. This is works well when the reason for the incident is a mechanical issue. When a pilot issue is identified then the focus on what happened leaves the reader thinking "I would never make that mistake, I am better than that guy." Everyone has probably read a story of a case of VFR flight into inadvertent IMC. It is easy from the armchair to conclude that you wouldn't do it but people still do. They are not more reckless than others. Any write up of an incident involving poor pilot decision making needs to be read with the right mind set. The reader need to be constantly thinking at what point would I make a different decision.

I suspect that many such occurrence's happen without event, then one day, all the holes line up, then we all read about it. One of the accidents mentioned previously, wasn't even inadvertent IMC, it had been deliberately done often, but they didn't get away with it this time. Many of the things that kill pilots seem to be done regularly, sometimes they get away with it sometimes they don't.

Tecky, I am not suggesting that anyone is too good to learn from the mistakes of others, but history says some of us don't. My point was that it seems to be the same mistakes on a regular basis, despite having been taught or regulated against.

 

 

[facthunter]

Where the same mistakes are made on a regular basis one would expect a specific remedy could be implimented. But are they the SAME mistakes?

 

People enter cloud for different reasons. The ones we are talking about probably didn't initially plan on doing it.

 

ALL CFIT are not the same. nor are all stalls but ones on base to final from a runway centreline overshoot are worth investigating as a need for technique study, specifically..

 

Wheelbarrowing , needs design/ technique attention.

 

Running out of fuel.... People do it in cars regularly these days. Not enough emphasis on attention to it. Perhaps occasional reminders in the mag and examples.

 

There's no case for not visiting incidents.. A lot want to know what happened so they can avoid doing it themselves if it's in their power to change things..

 

Learning from others mistakes is cheaper than from your own and you won't live long enough to make them all yourself.. Good example of that is individual aircraft groups working with each other to spread information that is helpful. Nev

 

 

[Nobody]

The FAA produces some pretty good guidance material on these subjects.

 

This first reference talks about 5 hazardous attitudes that a pilot may have. My concern with some of the incidient write up is that it tends to reinforce "it wont happen to me" attitude.

 

http://www.faa.gov/regulations_policies/handbooks_manuals/aviation/pilot_handbook/media/phak%20-%20chapter%2017.pdf

 

This second reference is also worth reading for its discussion on the attitudes that lead to errors.

 

https://www.faa.gov/regulations_policies/handbooks_manuals/aviation/risk_management_handbook/media/rmh_ch02.pdf

 

 

[Aldo]

For what it's worth I posted the below a couple of years ago and I still believe it's relevant to the current HF/accident discussion, knowing when to say no is the most important thing.

 

Flying is a manulitative skill (i.e. the more we do the better we get) so we are at the mercy of what we learn, doing what we like.

 

I don't know anyone who wants to die, so why do we get ourselves into situations in which this is the most likely outcome - confidence/overconfidence & peer/passenger pressure.

 

To fly well we require confidence, to gain confidence we need to practice/fly in situations that are at the limit of our abilities - i.e. we improve, when we do, the next time we are presented with the same situation we know that we have done this before and therefore we continue, thinking this will be no worse than the last time (if we do this without first having a way out we are heading for disaster).

 

The problem with this method is that sometimes we are not able to deal with the situation or are not able to make the decision to deal with the situation early enough that is at our limit or beyond and it ends in disaster, are we able to prevent this - yes & no - we need to understand when we are at the limit of our abilities and change our expected result - this is HF or airmanship.

 

Aldo

 

 

[facthunter]

Confidence must be related to actual ability. IF you feel your flying may have a few weak spots in it try to get some extra skills. This won't just fall in your lap and there is no silver bullet that "fixes" things. YOU will have to work at YOUR situation

 

You need a certain level of confidence to fly also. If you are apprehensive, you won't do your best, but if you are overconfident, you will attempt things you are not equipped for. There is nothing better than knowing what you are doing, and by inference, knowing what your limits are.

 

In a limit situation you will need to apply all the skill you have. Your body will realise this and your adrenalin will enable the extra effort and temporarily overcome fatigue. You heart rate will rise in relation to your increased (mental) effort. It is not unusual to have a heart rate over 200 in stressful flying situations.

 

( I'm NOT talking about PANIC, which won't help you at all.). Nev

 

 

[farri]

The International Ergonomics Association defines ergonomics or human factors as follows:[5] Ergonomics (or human factors) is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance.

 

 

Human Factors may explain why a particular situation has occurred,however, once all the Human Factors are taken into account and it shows the pilot was the cause, I don`t see the term, "Pilot Error," as a useless term,rather, a term to encompass all the known factors.

 

 

 

Frank.

 

 

 

 

 

[biggles]

The International Ergonomics Association defines ergonomics or human factors as follows:[5] Ergonomics (or human factors) is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance.

 

Human Factors may explain why a particular situation has occurred,however, once all the Human Factors are taken into account and it shows the pilot was the cause, I don`t see the term, "Pilot Error," as a useless term,rather, a term to encompass all the known factors.

 

Frank.

Frank , this article reproduced ,in part ,from Post #132 may be of interest ... Bob

 

" The study of human behavior is an attempt to explain how and why humans function the way they do. A complex topic, human behavior is a product both of innate human nature and of individual experience and environment. Definitions of human behavior abound, depending on the field of study. In the scientific world, human behavior is seen as the product of factors that cause people to act in predictable ways.

 

The Federal Aviation Administration (FAA) utilizes studies of human behavior in an attempt to reduce human error in aviation. Historically, the term “pilot error” has been used to describe an accident in which an action or decision made by the pilot was the cause or a contributing factor that led to the accident. This definition also includes the pilot’s failure to make a correct decision or take proper action. From a broader perspective, the phrase “human factors related” more aptly describes these accidents. A single decision or event does not lead to an accident, but a series of events; the resultant decisions together form a chain of events leading to an outcome. Many of these events involve the interaction of flight crews. In fact, airlines have long adopted programs for crew resource management (CRM) and line oriented flight training (LOFT) which has had a positive impact upon both safety and profit. These same processes can be applied (to an extent) to general aviation. "

 

 

[facthunter]

I don't wish to argue with you Frank. The term is not regarded as appropriate in investigation circles that are worthy of the name. It acts to simplisticly blame a ( often deceased) person and terminate with that alone. I won't pursue the topic . I think we are at cross purposes. Nev

 

 

[M61A1]

While looking for a quote about being "nibbled to death by ducks", I found this article http://sm4.global-aero.com/articles/tigers-and-ducks/ , which I thought would fit well here.

 

 

[John Brandon]

I find it hard to understand why the ATSB can publish accident findings and not get shot down by the Coroner but the rest of us can't. If ATSB have some sort of exemption by an act of parliament then why can't this same exemption be given to RAAus or any of the other RAAO's. I understand the ASRA advises it's members of accident findings.

All recreational aircraft accidents/incidents are, or should be, reported to the Australian Transport Safety Bureau. Section 12AB of the Transport Safety Investigation Act 2003 states: 'the ATSB is not subject to direction from anyone in relation to the performance of its functions or the exercise of its powers'. Thus a coroner cannot control the release of information by the ATSB.

 

Unfortunately ATSB is not a large organisation, perhaps around 100 personnel (it was required to reduce its numbers by about 10% in 2014) and is also responsible for rail and marine safety investigations so it lacks the resources to investigate recreational aircraft accidents, fatal or otherwise, and will not do so unless it considers the safety of the general public may have been threatened. ATSB does provide valuable laboratory assistance to RA-Aus investigations in the fields of metallurgical testing, extract of data from avionics etc.

 

So ATSB perceives RA-Aus as the organisation responsible for investigating RA-Aus fatal accidents, which results in a negative impact on the dissemination of information to the RA-Aus membership because coroners, in turn, only regard the RA-Aus investigators as part of the police investigation team assisting coroners and thus subject to coronial control in respect to dissemination of their fatal accident investigation reports, rather than properly regarding them as persons trained and appointed by RA-Aus management to do the crash investigation on behalf of the RA-Aus membership.

 

A fatality in a recreational aircraft accident is reported to a coroner by the police as an 'initial report' and the police subsequently maintain charge of the aircraft wreckage until all coronial procedures are concluded. The coroner may be a full-time coroner or a magistrate coroner who will investigate (with the further aid of police and other investigators) the circumstances surrounding the death. The law requires the coroner to establish the identity of the deceased; the medical cause of death (e.g. fatal injuries sustained in an aviation accident); when and where the death occurred and the circumstances surrounding the death i.e. what caused, or contributed to, the aircraft accident. After concluding an initial investigation a coroner may issue his or her findings without holding an inquest ('Findings without inquest') but an inquest may be held if the coroner believes it is in the public interest to do so and/or a 'senior' relative of the deceased requests it. The coroner maintains contact with the family during the coronial process.

 

An inquest is a public enquiry by a coroner's court into the cause of a death where various persons associated with the event, or persons thought able to provide 'expert' input, are required to attend and be questioned as witnesses. The coroner's findings, whether 'Findings of inquest' or 'Findings without inquest', may include recommendations to authorities in regard to systems, procedures and regulations with the intention of reducing the likelihood of similar accidents in the future.

 

However a coronial investigation is a long (sometimes incredibly long) but worthwhile, legal process. For example, the coroner's findings from the inquest into the death of research scientist Doctor Barry Uscinski provide informative, perhaps disturbing, reading; but the time elapsed between the accident and release of these findings was 50 months. The police investigator's report concluded that the accident was due to pilot error however the coroner had doubts and the family requested an inquest. The Findings of Inquest, determining that the accident was not due to pilot error, can be read at http://www.courts.qld.gov.au/__data/assets/pdf_file/0005/337622/cif-uscinski-20141229.pdf. The RA-Aus investigator's opinions seemed to form the basis of the coronial findings.

 

Surprisingly 'Findings without inquest' might also take a similar period to be published; for example, see the http://www.courts.qld.gov.au/__data/assets/pdf_file/0011/296435/cif-sweetnam-g-mitchell-a-20141015.pdf non-inquest findings for the Zenith Zodiac CH601 crash off Surfers Paradise in March 2008. Although this aircraft was VH registered the ATSB passed it on to RA-Aus thus confirming ATSB's good regard for RA-Aus investigative capabilities. RA-Aus was asked to assist the police investigation and it seems the coroner based his findings on the RA-Aus conclusions. The findings were published in October 2014 (6 years and 7 months after the accident) although in January 2009, RA-Aus issued an airworthiness notice AN070109-1 titled 'Compulsory fitment of a secondary canopy locking device, on Zodiac/Zenair/Zenith aircraft canopy'. This AN just states 'Several reports have been received indicating that the canopy fitted to Zodiac/Zenair /Zenith aircraft are opening in flight causing air turbulence around the tailplane and elevators' and does not mention that the death of two persons 10 months earlier was most likely caused by canopy detachment. Choosing this soft approach rather than making a statement providing more impact on RA-Aus members was probably done to avoid pre-empting the coroner's findings however a bit of judicious wording could have informed the membership of the likelihood of canopy detachment being involved in the deaths of two persons.

 

It is not easy for the RA-Aus membership to locate coroners' findings on the internet; for example the RA-Aus website contains only two references* to coronial findings, one reveals 32 months between the accident and the date of the finding, the other is 54 months. Obviously a report on an event that occurred 4-6 years previously would be regarded as history by most RA-Aus members reading the coronial findings (particularly those many members who joined the association well after the reported accidents). Grossly delayed accident reporting lacks immediacy in its impact on the membership. It appears that the current national standard for coroners’ courts is that no lodgements pending completion are to be more than 24 months old, so perhaps recreational aviation accidents are regarded as less important and tend to drift toward the back-burner.

 

*The fact that the RA-Aus website contains only two references to coronial findings is rather strange as one would presume RA-Aus, as active participants in coronial investigations, would be on the distribution list when the findings are published.

 

Fatal recreational aviation accidents keep increasing while coronial investigations drag on. The Doctor Barry Uscinski inquiry took 50 months to complete but in a 50 month period between January 2011 and February 2015 inclusive, 29 RA-Aus accidents killed 38 persons and destroyed 30 aircraft. On top of that it was only extraordinarily good fortune that the October 2011 controlled flight collision with an operating Ferris wheel at Old Bar, NSW did not add members of the public at large to the toll. Recreational aviators are most certainly not getting safer, despite the introduction of human factors training and the more recent managerial measures. Perhaps the adage 'The more things change, the more they stay the same' is appropriate? The biggest problem is probably most pilots believe 'it can't happen to me!' I think recreational aviation might need some shock treatment and probably only extensive, perhaps even graphic, publication of the causal factors and the resultants of all 76 fatal accidents that have occurred since January 2001 might have sufficient shock value.

 

Most of the above is extracted from the tutorial page at http://www.recreationalflying.com/tutorials/safety/intro2.html

 

John Brandon

 

RA-Aus Life Member