Light plane crashes in SA's South East

[Yenn]

SSCBD commented that back in the day there was no human factors training. I beg to differ. Baxk in the day it was called airmanship and the old hands expected to see it in the new chums. Same thing, different name and in my opinion the old way was just as good.

 

The same applied to industry, safety was always there but we didn't have proffessionals doling it out.

 

 

[turboplanner]

SSCBD commented that back in the day there was no human factors training. I beg to differ. Baxk in the day it was called airmanship and the old hands expected to see it in the new chums. Same thing, different name and in my opinion the old way was just as good.The same applied to industry, safety was always there but we didn't have proffessionals doling it out.

I think the "airmanship" concept came in in the late 1930s in response to the appalling carnage taking place in "joyflights" and "stunt" flying by amateurs.

It addressed human factors by motivating pilots towards a safer way of operating, thinking before acting, and following safe procedures.

 

There wasn't a written communication, more of a handing down line line from the more experienced pilots.

 

I can remember as a kid watching two pilots doing a start up on a Tiger Moth, and the exchange and procedures between the two were an education, and if anything, better than what you see today.

 

The second world war took airmanship to a new level as pilots were killed in silly accidents and training away from the battlefields. I read that more trainee pilots were killed at Mildura training on Beaufighters than were killed in battle.

 

By the 1950's the flying standard in Australia was claimed to be the best in the world, and a lot of people on this forum would have met those old professionals, and may been stung by them for screwing up, even for the most minor transgressions.

 

By the end of the 1950s Cessna, Piper and Beechcraft in particular were cashing in on the post war boom, selling a message of flying cars, telling people that anyone could fly these new aircraft, they weren't much different to a car. That BS went on through the early 1960s until the carnage became too obvious and people started to sue based on the BS they had been told

 

However, we had a new generation of risk takes, short cut takers, and others who just didn't know what they didn't know.

 

The beautiful symmetry of the old timers following their check procedures disappeared, and operation of aircraft was more haphazard.

 

By the 1970s it was necessary for the Aviation Safety Digest to run special features on flying the older aircraft like tigers, where pilots were regularly doing ground loops, smashing props, and getting cut up during slovenly starting procedures etc.

 

In the decades since, ATSB have identified a lot of accidents caused by silly mistakes, non-professional behaviour, dumb thinking etc. and called it human factors.

 

I don't doubt the statistics and the potential to save lives by changing the culture back to airmanship or some other name which encourages pilots to be professional, but the CASA thought bubbles on what HF is, and the training material they provided seem to have been totally ineffective. Time for a Take 2.

 

 

[onetrack]

Professionalism and the safety culture, is simply taking and distilling the accumulated knowledge of the old fellas and putting it in a formal readable form, for dissemination to newcomers, the young, and the inexperienced.

 

I was brought up in the earthmoving/construction and agricultural industries. I was taught by the old fellas, who had never seen a book with safety rules and skills outlined.

 

They knew it all, though, and transferred it to us young blokes by constant supervision, by on-the-job practical training, and by arse-kicking when we did stupid, thoughtless things, that were dangerous.

 

Roll forward to the nineties and I was one of three senior family members running a large mining contracting business, moving the earth for the biggies.

 

About then we had professional, university-educated mining engineers requiring - no, demanding - operation handbooks, safety handbooks, cover-your-arse-for-every-situation, handbooks.

 

We wrote them up, turning our "professional" knowledge into readable forms. Other contractors copied our handbooks, often word-for-word.

 

A lot was just plain, simple stuff, such as "wear your seatbelt when driving our vehicles, or you will more than likely die".

 

A number of the operation and safety manuals were more intensive and covered very important things employees had to know.

 

Bottom line was, after 30 years of being in business, we only ever had one fatality out of a workforce that eventually ranged from around 65 to 103 employees.

 

That fatality was a keen and likeable young bloke (aged 20), who was in such a hurry, he failed to fasten his seatbelt when driving on a superb, dual-lane highway in sunny, clear weather at midday.

 

He drifted off the road through inattention, hit a wooden roadside guidepost - which snapped in half - and incredibly, one half stood up at 45 degrees as it came out from under the LH front wheel - it hit the LH rear tyre smack dead centre, and punched a hole straight through it, totally deflating it instantly.

 

The young bloke casually swerved back onto the bitumen (as we've all done) - but the flat LH rear tyre produced immediate and violent oversteer that sent the Hilux sideways across the bitumen at 110kmh.

 

The result, with an unfastened seatbelt was entirely predictable - the Hilux rolled three times, he was thrown out the passenger side window, hit the road head-first, and he was history. It was very sad end to a young bloke who was a good employee, keen, and a "go-getter".

 

Human resources people writing up laws and regulations and instructions, and enforcing them, have done a great deal to reduce unnecessary deaths and injuries in every industry.

 

However, they wring their hands over the people they call, "known risk takers".

 

These are the people who take dangerous short cuts, ignore basic lessons and instructions, and who consider themselves immortal.

 

These are the people training institutions and regulators need to focus on - with less of the "penalty mentality" and more of the "correction and education and warnings" instruction.

 

I will wager that both pilots in the Horsham and Mt Gambier crashes fell into the above-noted "risk-taker" category - people who are "go-getters", often impetous, often arrogant - and often poor decision makers, who fail to see the dangers in their lapses towards major risk-taking.

 

Often, they see the risks they take as "minor", when they are actually "major".

 

This is the area where regulators need to be more active, not on the "more regulation and higher penalties" areas.

 

 

[facthunter]

Human factors are not just commonsense. Most who think they don't need it are the worst offenders. I've seen some "ACE" airline types (They think they are)make absolute fools of them selves trying to show it's not needed for them. Don't judge it by what you have been shown so far. It's well short of an optimum presentation . People continue to demonstrate they need human factors knowledge and attitude modification. Knowledge does modify behaviour and improve performance. Those who think they know it all are potentially dangerous. Never stop learning and critique your performance honestly and don't say I'm good enough already. Like "accidents happen to OTHER pilots"... Wrong.. Nev

 

 

[cooperplace]

Never stop learning and critique your performance honestly . Nev

100% agree; a vital factor is the honesty: owning up to mistakes. We all make them.

 

 

[Mick]

Most members of the public would have the expectation that the safety level would be the same as a QANTAS flight, unless they were briefed otherwise.

If this is true why do most "Joe Publics" tell us flyers that any plane smaller than a Dash 8 is dangerous?

 

 

[M61A1]

Human factors are not just commonsense. Most who think they don't need it are the worst offenders. I've seen some "ACE" airline types (They think they are)make absolute fools of them selves trying to show it's not needed for them. Don't judge it by what you have been shown so far. It's well short of an optimum presentation . People continue to demonstrate they need human factors knowledge and attitude modification. Knowledge does modify behaviour and improve performance. Those who think they know it all are potentially dangerous. Never stop learning and critique your performance honestly and don't say I'm good enough already. Like "accidents happen to OTHER pilots"... Wrong.. Nev

Damn right it's well short of an optimum presentation.

I have been on the receiving end of HF for almost two decades, mostly HF in aviation maintenance, with various companies, with various contracts, some it very relevant, most it just awfully presented and useless. I have found it much better to seek out information yourself. With mandatory refreshers every year, there are only some many times you can feign interest in the same PowerPoint slideshow and be examined on the difference between errors and violations.

 

Absolutely agree about honest self critique though and understanding that it could very easily be you if you give Murphy a chance.

 

 

[turboplanner]

If this is true why do most "Joe Publics" tell us flyers that any plane smaller than a Dash 8 is dangerous?

There are certainly a lot of people who believe that, and I once worked with a Company which would not allow charter in single engine aircraft.

I was one of the people who listened to the stories about so and so being a "very safe" pilot some time before so and so wiped himself out in one of his usual low level displays, and on one holiday took a helicopter ride with my family to the top of Fox Glacier in New Zealand.

 

On the way back down, unrequested, the pilot decided to charge at the cliff face and turn at the last minute. I was mildly concerned at the safety of that turn which felt in excess of 2 g.

 

A week later, same flight, same day the helicopter crashed killing everyone on board.

 

In this case, what counts is the people believing they were taking a safe flight, and the report of plaintiff lawyers taking action to secure the assets of a late pilot indicate that unless the matter(s) are settle out of court, we will learn more about the perceptions of a passenger taking a flight in a light aircraft.

 

 

[Yenn]

Having grown up in the age before HF and going through airmanship as a student pilot. Also having worked in agriculture and construction industry I was always aware of job safety. I once refused to promote a man as leading hand, much to the bosses ire. He was moved to a different job and dead in a few weeks because he was too much rush and tear in a dangerous job.

 

Then along came HR and all we got was lectures and always being told what we were doing wrong. One of those HR people passed me on the way to work, doing over 100k in a 60 zone and when I mentioned it to them they said it was OK if you didn't get caught. What a lovely example. The examples are never ending, it all seems to be lip service. In my last few years at work I used to fail all the safety exams on purpose, but I always ended up with the blue, gold or whatever card it was.

 

Maybe you can se why I don't like HR.

 

 

[turboplanner]

I see HF and HR as two separate things Yen,

 

HR beingv a disease.

 

I view Human Factors as doing something accodentally that you normally wouldn't do; like Douglas Bader's crash when he tried to take his Spitfire off in coarse pitch.

 

 

[onetrack]

Just a correction - Baders official logbook entry for the crash that cost him his legs, simply states, "crashed slow-rolling near ground" - not a crash on takeoff caused by incorrect prop pitch setting.

 

'Bad show': Douglas Bader's stoical logbook entry on crash that cost him his legs | Daily Mail Online

 

 

[facthunter]

The concept of good airmanship is a good start, but it's not the end of the matter. World wide it's considered as the most cost effective safety improver.

 

Resource management, OK something's wrong, I've got myself on top of 8/8 cloud but the radio works so I can get radar to assist me or ATC to just talk to me or I have a GPS and the autopilot works. and do a 180 turn...

 

.Human factors (are you tired, Hung over, dehydrated, stressed, angry, Trying to prove something, Showing off, desperate to get home, suffering from acute anxiety, carbon monoxide, sun glare, eyesight needing glasses, but put it off. Haven't Learned how to scan properly . etc A far less than complete list hopefully illustrating the nature of the concepts. Nev

 

 

[pmccarthy]

Badgers crash was in a biplane.

 

 

[onetrack]

Baders crash was in a biplane

Correct ...

 

"Commissioned as a pilot officer on July 26, 1930, Bader received an assignment to No. 23 Squadron at Kenley.

 

Flying Bristol Bulldogs, the squadron was under orders to avoid aerobatics and stunts at less than 2,000 ft. of altitude.

 

Bader, as well as other pilots in the squadron, repeated flaunted this regulation.

 

On December 14, 1931, while at the Reading Aero Club, he attempted a series of low altitude stunts over Woodley Field.

 

In the course of these, his left wing hit the ground causing a severe crash.

 

Immediately taken to Royal Berkshire Hospital, Bader survived, but had both his legs amputated, one above the knee, the other below."

 

 

[turboplanner]

Just a correction - Baders official logbook entry for the crash that cost him his legs, simply states, "crashed slow-rolling near ground" - not a crash on takeoff caused by incorrect prop pitch setting.'Bad show': Douglas Bader's stoical logbook entry on crash that cost him his legs | Daily Mail Online

The crash I referred to occurred after he lost his legs. He only realised he was in coarse pitch after he had come to a stop, and in the gentler writing of the time uttered one short sharp unprintable word. He autographed my book for me.

 

 

[facthunter]

Without casting aspersions, a power check just after applying full throttle on the take off run, should be part of every pilot's training.. If you have a very short runway full throttle on the brakes is common practice. If the engine is rough, not making revs (with a fixed pitch prop) AND not making revs with a CS or adjustable pitch prop, and making revs but not the normal Manifold pressure, you should abort the take off. The last situation will be very noticeable early. Most larger CS Piston props are exercised during the engine run up where the full range of pitch is checked and the feathering pump.(s)

 

The BASIC checklist was hatches, harnesses, trim, mixture, PITCH, fuel, flaps, instruments, switches , Controls . Nev

 

 

[M61A1]

Having grown up in the age before HF and going through airmanship as a student pilot. Also having worked in agriculture and construction industry I was always aware of job safety. I once refused to promote a man as leading hand, much to the bosses ire. He was moved to a different job and dead in a few weeks because he was too much rush and tear in a dangerous job.Then along came HR and all we got was lectures and always being told what we were doing wrong. One of those HR people passed me on the way to work, doing over 100k in a 60 zone and when I mentioned it to them they said it was OK if you didn't get caught. What a lovely example. The examples are never ending, it all seems to be lip service. In my last few years at work I used to fail all the safety exams on purpose, but I always ended up with the blue, gold or whatever card it was.

Maybe you can se why I don't like HR.

As previously mentioned, done right it's very useful. Based on my experiences, which appear similar to yours, they would do well to teach the whole company about HF.

One example being that they always use the the BAE 146 window blow out as an example. One of the causal factors listed is poor lighting. However it still takes years to get our purchasing clowns to acquire a few decent flashlights to do before and after flight inspections and other maintenance. Just one example of many that have me quite convinced that it's a box ticking exercise. Have your HF refresher and get back to work, "don't forget to sign the sheet on your way out, or you'll have to do it again".

 

The managers above are very sincere about HF, but they need to let the whole system (bean counters and other parasites) in on it, not just those on the coalface.

 

 

[turboplanner]

The SMS ensures that. Sounds like you don't have one, or yours isn't satisfactory, because ALL employees are involved; otherwise you would have the accountants instructing purchasers not to order torch batteries for whatever reason was the flavour of the day.

 

 

[Guernsey]

Just a correction - Baders official logbook entry for the crash that cost him his legs, simply states, "crashed slow-rolling near ground" - not a crash on takeoff caused by incorrect prop pitch setting.'Bad show': Douglas Bader's stoical logbook entry on crash that cost him his legs | Daily Mail Online

Absolutely correct, I know because I saw it all happen with my own eyes in the movie. .

 

Alan.

 

 

[facthunter]

I though that is what accountants do. Say we can't afford that or the dividend will not meet expectations. Nev

 

 

[ben87r]

I remember once with a different company, we "couldn't afford" the Mags for one of our two AC in the base. I was turning down 5k+ a week in work until they eventually 'let us win', owner the same month spent a large sum of money on a toy.

 

I don't trust accounts with money, let alone Saftey.

 

 

[turboplanner]

I though that is what accountants do. Say we can't afford that or the dividend will not meet expectations. Nev

Or, "we'll fix it in the new financial year before the next accident."

 

 

[M61A1]

The SMS ensures that. Sounds like you don't have one, or yours isn't satisfactory, because ALL employees are involved; otherwise you would have the accountants instructing purchasers not to order torch batteries for whatever reason was the flavour of the day.

What makes you think that there is no SMS? I can tell you without any doubt that there is a SMS, as well as Quality Management, and Training Management, The trouble is too many rules and no common sense, the bigger the company, the worse it is. The process is so rigorous, that for some, it's just easier not to bother.

Any aircraft job I sign off on as a tradesman or supervisor, has to (assuming that I have been assessed as "Competent" and subsequently " Authorised") be completed IAW the aircraft pub, as well as any Tech Notes and Maintenance Directives, while simultaneously meeting safety, environmental and Quality processes.

 

The Safety people sit in their office making rules, while getting tradies to do their audits, as do the Quality people.

 

I spoke to a young fellow at Bunnings the other day, who was so frustrated at not be allowed to cut some flooring because although he had been trained to use the machine (yes the one where you press the button and the rolls go up and down on a chain), the person who was authorised to authorise him was on holidays. So we waited for an authorised employee to come who subsequently turned the key and pushed the green button until the roll I wanted was in front of us.

 

It's a wonder we can produce anything in this country, where every employer is expected to be like a "special" school.

 

 

[facthunter]

Trouble is the bad execution of these programmes gives the concept a bad name. Perhaps more critical auditing of the implementation is needed, but no one likes that. Self management is an oxymoron, where trust is hoped for. When the Cat's away the Mice play. Nev

 

 

[turboplanner]

What makes you think that there is no SMS? I can tell you without any doubt that there is a SMS, as well as Quality Management, and Training Management, The trouble is too many rules and no common sense, the bigger the company, the worse it is. The process is so rigorous, that for some, it's just easier not to bother.Any aircraft job I sign off on as a tradesman or supervisor, has to (assuming that I have been assessed as "Competent" and subsequently " Authorised") be completed IAW the aircraft pub, as well as any Tech Notes and Maintenance Directives, while simultaneously meeting safety, environmental and Quality processes.

The Safety people sit in their office making rules, while getting tradies to do their audits, as do the Quality people.

 

I spoke to a young fellow at Bunnings the other day, who was so frustrated at not be allowed to cut some flooring because although he had been trained to use the machine (yes the one where you press the button and the rolls go up and down on a chain), the person who was authorised to authorise him was on holidays. So we waited for an authorised employee to come who subsequently turned the key and pushed the green button until the roll I wanted was in front of us.

 

It's a wonder we can produce anything in this country, where every employer is expected to be like a "special" school.

Sounds like there's a comprehension problem there.