Positive no blame reporting culture

[Bruce Tuncks]

While this would be great, I personally doubt that it exists.

My current advice to a near-miss person would be to keep it quiet. Gosh I would like to be proved wrong on this.

Does anybody have any experience where the pilot should have kept quiet, or a positive experience where they told of a big stuff-up and were thanked instead of being penalized?

[turboplanner]

While this would be great, I personally doubt that it exists.

My current advice to a near-miss person would be to keep it quiet. Gosh I would like to be proved wrong on this.

Does anybody have any experience where the pilot should have kept quiet, or a positive experience where they told of a big stuff-up and were thanked instead of being penalized?

We already have that and I'm not aware of anyone being prosecuted after using it. The policy is designed to encourage people to come forward and admit their mistakes so they can be analysed and all airmen learn from them.

You take a personal risk advising other to keep quiet, particularly when they would have had the protection of the above policy. You become part of the incident.

The Safety Digests have hundreds of positive experiences on record after the pilot self-reported.

[Bruce Tuncks]

Just tonight on the news there was this pilot who crashed on take-off from PNG with 500 kg of drugs on board. I think he is going to jail for ever.

[Old Koreelah]

...

My current advice to a near-miss person would be to keep it quiet. Gosh I would like to be proved wrong on this.

Does anybody have any experience where the pilot should have kept quiet, or a positive experience where they told of a big stuff-up and were thanked instead of being penalized?

Bruce I'm with Turbs on this; the regulator paid me $500 to tell fellow flyers about when I broke several safety rules. I learned heaps from the experience and hopefully so did others.

[walrus]

No blame reporting culture doesn’t exist any more.

 

Two examples from my time as a student in GA not RAA.

 

1. Do not use a rag or wad of paper to plug ANY orifice during maintenance, use a correct plug or fitting. That one resulted in a fire, $12000 damage and a few dinner party stories. When the smoke started, I did a very neat circuit at 200 ft while my instructor did the radio.

 

My understanding is that one may have been written up as a “random” bit of paper being blown into an unfortunate location so as not to reflect on LAMES.

 

2. Do not EVER do touch and goes with flaps when learning STOL techniques on short unimproved airstrips without determining your climb capability. . Plan for a full stop or go around from a safe height before you are committed. That one nearly killed me and my instructor. It should have been written up and even perhaps published. No written report was produced because it would have been an admission that the school and its instructors were less than perfect. The instructor is now in jets.

Edited August 1, 2020 by walrus

[tuffnut]

I'm all for 'self reporting'.....20 years after it happened:cool:. No sense in 'crashing' twice...NEVER trust a bureaucracy.

[turboplanner]

Governments offloaded public liability for this very reason; they knew what caused accidents, they knew the people involved knew, but they were left to face the victims and the victims sued the governments.

These days we carry our own public liability; if we are negligent we pay, but even under that there is a percentage that don't care. In the transport industry the drivers would just be hung out to dry if for example they caused an injury or fatality through being fatigued, even though their boss had told them to ignore sleep breaks and get the freight in by a fixed time, or a large customer had told the freight company to deliver a product at a certain time or they would lose the co ntract. Governments introduced Chain of Responsibility legislation and many customers in the management chain have been fined. Worksafe on July 1 introduced some tickler legislaton with prison sentences and fines of up to $16.5 million for workplace offences. It was announced on Friday that the Victorian Manager of a freight company where the driver crashed into a police scene killing four police officers has been arrested and will be charged under new laws. It's a changing scene but as recalcitrant as we might be, we are slowly being ground into taking responsibility for our own actions.

[Flightrite]

"Just culture" is a fancy feel good BS in the aviation industry, designed to make you feel good for being human, only trouble is the 'big stick' approach is just lying there below the surface!

[Mike Borgelt]

No problem with governments offloading liability as long as they don't make any rules or let others make rules for you. If you make the rule it is YOUR rule and you are liable if someone follows the rule and has a problem as a result.

So victims sue governments? The governments have lawyers on tap, infinitely deep pockets and forever to stall you while you pay lawyers out of your own pocket. Dumb idea.

[Jim McDowall]

The idea that there has to be public liability (and thus insurance) is a legal construct. Governments are free to make laws for "peace, order and good government". For example, the Commonwealth and CASA are not liable "in negligence or otherwise for any loss or damage incurred by anyone because of, or arising out of, the design, construction, restoration, repair, maintenance or operation of a limited category aircraft or an experimental aircraft, or any act or omission of CASA done or made in good faith in relation to any of those things." -CASR 201.003

Similarly, they could make a law that no-one is liable in the operation such aircraft or limit the circumstances in which liability existed eg to protect people on the ground not at an aerodrome. After all they are signatories to a treaty which limits the liability of international passenger carriers.

[facthunter]

I believe you can't ethically contract out of a liability you as responsible Authority are accountable for.. . If you still conduct audits and something goes wrong are the audits, rules education etc effective? Wilful negligence or blatant disregard of rules, is what you should apply to ALL including the authority. in aviation.

Briefly, CASA applied "Human Factors" to accident/ Incident investigation in the past, but THAT stuffed the Law of Strict Liability so they ran a mile from it but made the Industry be qualified in it at the same time. The more strict penalties applied the more secret will the operation be. It's a natural consequence of the current one sided situation. You don't have to actually write off a plane to Know you nearly did. People CAN profit from other's experiences and mistakes IF the system is appropriately designed. Nev ..

[Jim McDowall]

Ethics and Government, you must be kidding.

[Yenn]

The system we have works and I have used it. I don't want my stupid mistakes to be copied by another person. Let others know where you have failed so that they can avoid failure.

The other point is, that if you speak up, you will not be prosecuted unless it was an obvious illegal move.

[Flightrite]

Ethics and Government, you must be kidding.

 

Yes a contradiction in terms to me sure!!

[Jase T]

A lot depends on the current culture in the regulators. I once self reported a “possible” N2 over speed and was hung out to dry by the investigators. Basically the copilot called “N1” whilst we were manoeuvring thenaircraft. I was pilot flying at the time. We both observed the N2 at redline and reducing. We never observed it exceed the limit but at it and reducing. Given the gov should have prevented the overspeed I was not too worried. Maintenance decided it may have and as we don’t know by how much decided t could have been a major and replacced the engine, gear box’s etc etc etc all requiring overhaul due to major overspeed... it was therefore classed as an accident!!!! I could have not reported it! Would not have been any further issues.... Would I have suggested a junior pilot report in the same situation?? Not at that time. But there was a culture shift later and then yes I would!

[APenNameAndThatA]

A lot depends on the current culture in the regulators. I once self reported a “possible” N2 over speed and was hung out to dry by the investigators. Basically the copilot called “N1” whilst we were manoeuvring thenaircraft. I was pilot flying at the time. We both observed the N2 at redline and reducing. We never observed it exceed the limit but at it and reducing. Given the gov should have prevented the overspeed I was not too worried. Maintenance decided it may have and as we don’t know by how much decided t could have been a major and replacced the engine, gear box’s etc etc etc all requiring overhaul due to major overspeed... it was therefore classed as an accident!!!! I could have not reported it! Would not have been any further issues.... Would I have suggested a junior pilot report in the same situation?? Not at that time. But there was a culture shift later and then yes I would!

How long ago was that? What do you mean by hung out to dry? Can you make the story clearer about what happened? Did the copilot call out the wrong number?

[Jase T]

How long ago was that? What do you mean by hung out to dry? Can you make the story clearer about what happened? Did the copilot call out the wrong number?

 

Mid 90’s. Nope copilot callout was correct a parameter was approaching limits. This engine (Lyc T-53) had no recording system so there was no way to know the actual value reached. Hung out to dry means there was a lot said and done that I disagreed with. Basically the N2 in a turbine engine is the compressor stage attached to the gearbox attached to whatever it’s turning. So overspeeding that overspeeds gearbox’s, accessories, pumps, and lots of expensive parts. If you overspeed by a certain amount (major) it’s pretty much take every part and throw it in the bin! There are a number of gov’s that should have prevented it actually overspeeding and to this day I don’t think it did. I reported it to be safe. Can’t edit original post to fix my typing errors (pressed post instead or preview) so sorry for the grammar.

Edited August 3, 2020 by Jase T

[Bruce Tuncks]

If there is a risk that blame might result, then why not report something in such a way that it can't be traced back to you?

I have been known to attribute things to an unspecified " mate" when it was me all along but there was not enough trust for me to be completely honest. Not that I have ever done an official report. Let them come here say I.

There was a story on this forum from a guy who carefully reported every little thing from his flying school because he thought this was the right thing to do... until he was officially investigated for having " about twice the incidents as average ".

[Jase T]

And I will correct my error N2 is a turbine stage not a compressor stage in the T53. N1 is connected to the compressor. N2 only to the gears.

[M61A1]

Mid 90’s. Nope copilot callout was correct a parameter was approaching limits. This engine (Lyc T-53) had no recording system so there was no way to know the actual value reached. Hung out to dry means there was a lot said and done that I disagreed with. Basically the N2 in a turbine engine is the compressor stage attached to the gearbox attached to whatever it’s turning. So overspeeding that overspeeds gearbox’s, accessories, pumps, and lots of expensive parts. If you overspeed by a certain amount (major) it’s pretty much take every part and throw it in the bin! There are a number of gov’s that should have prevented it actually overspeeding and to this day I don’t think it did. I reported it to be safe. Can’t edit original post to fix my typing errors (pressed post instead or preview) so sorry for the grammar.

I will assume you were flying a Huey. Sounds like a massive over reaction.

I have had to help sort out an actual overspeed an a B206. The power turbine governor did fail(resulting in an STI to inspect all of them). The instructor pilot took over and landed the aircraft on a ridge. there were no data recorders other than CVR, which they used to determine main rotor frequency. From memory, they figured that it had exceeded 420 rotor rpm, a considerable overspeed from mid 300's. The whole driveline was replaced, including the engine and rotors.

N2 is usually the power turbine and directly related to Nr or rotor speed. N1 or Ng is the gas producer speed, But you know that....just for clarity for others.

[facthunter]

You are given a figure for overspeed and that's it. Whatever happens then is a documented process that follows. Not reporting it as not a responsible option. Others fly the planes you have flown and should reasonably expect to be informed of the true airworthiness condition of it. Heavy landings are another example but don't have meters to register limits. Often the pilot will just use reasonable judgement. "G" meters have a register of MAX readings which you can reset..In emergencies one may choose to deliberately exceed limits, but you will certainly have to justify it. If it's a malfunction your warning indications may be quite benign. A stick shaker on late final certainly is not but it was a false warning that freaked out the Co pilot..Just something else to cope with. Nev

[Flightrite]

Engine manufacturers had to draw a line in the sand somewhere regarding an over temp. Engines don't just blow up 1 deg over the manufacturers set limit, turbine engines are actually very robust but it's the longevity that comes into question if multiple exceedences have occurred.

[M61A1]

You are given a figure for overspeed and that's it. Whatever happens then is a documented process that follows. Not reporting it as not a responsible option. Others fly the planes you have flown and should reasonably expect to be informed of the true airworthiness condition of it. Heavy landings are another example but don't have meters to register limits. Often the pilot will just use reasonable judgement. "G" meters have a register of MAX readings which you can reset..In emergencies one may choose to deliberately exceed limits, but you will certainly have to justify it. If it's a malfunction your warning indications may be quite benign. A stick shaker on late final certainly is not but it was a false warning that freaked out the Co pilot..Just something else to cope with. Nev

Actually for some there are degrees up to a point. Some will have limits based on how much and for how long you had the over speed, same for over torque and over temps.

in the case I mentioned there was much consulting with Bell. They decidedthat they had never tested any of the components to that point and recommended replacement, but had it been minor there were different components to replace or inspect depending on the degree of over speed.

[facthunter]

Do YOU wish to fly aircraft that have exceeded stipulated limit figures and not been documented? . Of course they don't just disintegrate a few rpm or degrees over but that's not the issue. You are not entitled to make presumptions. Emergencies I've covered. Nev

[M61A1]

Do YOU wish to fly aircraft that have exceeded stipulated limit figures and not been documented? . Of course they don't just disintegrate a few rpm or degrees over but that's not the issue. You are not entitled to make presumptions. Emergencies I've covered. Nev

They still get documented, and the necessary inspections are carried out in accordance with the manufacturer’s publications. The point was that it’s not completely black and white, there are degrees. For the record, I have flown in nearly all the aircraft I have performed such inspections on. I would happily fly in any of them, but some I am not permitted to..