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Yenn

Accident and defect

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 What ATSB investigate and why might be questioned but the quality of their investigative process is generally accepted as fair and impartial. They are open to the public supplying information and opinion.

       Things were better when it was an Aviation only organization though some commercial pressures may have been exerted  on occasions...Coronial investigations bring up some very "not aviation savvy" statements at times, which may be totally irrelevant unintentionally just by lacking aviation "Knowledge" which is quite specialized since only a small % of the population get involved in it other than as a passenger, generally on RPT.  Nev .

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I had another look today and the situation is getting worse. Not only are there few actual write up of what happened, but it seems that on the same day, 2 different planes had he same incident at Mildura. Funny one was in Vic and the other was in SA.

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19 hours ago, Yenn said:

I had another look today and the situation is getting worse. Not only are there few actual write up of what happened, but it seems that on the same day, 2 different planes had he same incident at Mildura. Funny one was in Vic and the other was in SA.

Without an army of volunteers on the ground in all States, monitoring what is happening is always going to be hit and miss, relying on complaints from the public, information from concerned instructors, pilots and ground staff, reports from pilots, and investigations by police and ATSB. Even so, in the past when this was collated by skilled people it produced about 30 incidents a month we cold all learn from. When the quality breaks down to the point where a flat tyre is listed as an engine failure, or is as sloppy as you're saying, it's not a good look.

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I seem to recall some stats that found that upon implementation there was usually a spike in reporting, followed by a significant drop off as people started only reporting worthwhile events.

Or maybe people have realised that even when they do report, there is nothing to be gained???

For that which I have personally reported, I thought the process which followed was rather poor and nothing more than the usual box ticking.

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  ATSB are supposed to be" at a distance " (independant) and I have no proof they aren't, but it's not just aviation they deal with..  Fatals (non aerobatic) are generally looked at though some non fatal newsworthy things Like the Old BAR Ferris wheel "Incident" seemed a bit political to me. Nev

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1 hour ago, fly_tornado said:

I thought the PIC submitted the incident report if capable?

Yes, but how many are doing it, or submitting a report containing all the facts? The published reports being criticised as done by someone in the office could be all they received.

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24 minutes ago, facthunter said:

  ATSB are supposed to be" at a distance " (independant) and I have no proof they aren't, but it's not just aviation they deal with..  Fatals (non aerobatic) are generally looked at though some non fatal newsworthy things Like the Old BAR Ferris wheel "Incident" seemed a bit political to me. Nev

They have the right to make their decisions, but that one was probably due to the potential disaster, and what became public of the events leading up to the hit. I wouldn't say it was political.

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They have the obligation to be impartial, and to look at causal factors. I wouldn't doubt at times there would be attempts to 'influence" which  ones are investigated. The way the plane was operated and the siting of the Ferris wheel were the issues,. Not the way the plane was built.  The Ferris wheel should never have been where it was. Nev

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The Old Bar investigation went around and around, eventually going nowhere. Got all hung up in the detail apparently.

 

 

 

(COME ON.. someone had to!):wasnt me:

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11 hours ago, M61A1 said:

For that which I have personally reported, I thought the process which followed was rather poor and nothing more than the usual box ticking.

You hit the nail on the head.  It's ALL about the PROCESS or more correctly having the process.

When the RAA are asked about their accident reporting, they can proudly say "Yes, we have a process for that".

What is written and what the results are, are irrelevant....... 

 

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They write verbatim what is sent to them, to do anything else could alter the report. Its self reported which has a heap of issues including that the report is firstly done after surivable accidents, and then its can be worded with CASA, RAA and insurance in front of mind.

Poor classification of accident causes needs improvement as this is how data is used in the future.

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They do not write verbatim. I put in a report a few years ago and they garbled it and made it look as if I had not done a daily inspection. It took some time for them to correct the report. They are just incompetent and do not care if the reports are meaningful or not. As they are at present they are useless as far as promoting safety.

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My incident even had spelling errors brought across, you might have got the point across to not fiddle with info

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While I really don't care whether or not what is written is reported verbatim, what matters is whether it is accurate. My issue is what use is the information and the process if it is just to satisfy a process?

What really got up my nose about an incident I reported was that I had someone on the phone who couldn't accept that there was nothing I could have done differently except stay home and don't aviate, because they need something to sign off (for want of a better term) to say that there was an educational element or box to fill.

There is no acknowledgement that the procedures followed resulted in an excellent outcome, which potentially could have easily been much worse. All they were pressing for was "What would you do differently?"

A response of "Nothing, it all went textbook" wasn't something that fit their box.

Also, we all have to learn Human Factors, but what use is it when the term "Human Factors" is just used to replace the term "Pilot Error"? The very idea of Human Factors training is to find out why the pilot made the error/s. Establish the chain of events to find the reasons decisions were made and actions carried out, then see what, if anything can be done to ensure a better outcome in the future, not just replace one term with another.

That said, I consider it quite likely that we are better off this way, because if they do implement it properly, there will be a lot of people who won't be flying, either because they won't be allowed or can't afford it.  If we want them to spend millions with the ATSB investigating every accident, we will end up paying one way or another.

It's recreational flying, we're not RPT, and as long as the limit the risk exposure to the public, I personally am happy to control my own risks.

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55 minutes ago, turboplanner said:

You should have asked them to call me M. I could have translated for you.

May I ask what you might have said?

I just ended up making sh1t up, so they would go away, as their suggestions were completely impractical as usual.

The follow up phone call was hardly encouragement to do another one should there be any further incidents.

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Insurers now ask all the same type of questions and cant handle the answer that all care was taken and it was a accident that no amount of preventative cost or analysis could forsee.

Maybe this is the continuation of safety at any cost mentality across lots of industries.

Its your responsibility to prevent accidents therefore if there is one its your fault.

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It is not a continuation of safety at any cost.

It is a "Look how good we are at promoting safety"

Just another case of big noting themselves for a job very poorly done.

We used to have an appropriate word for human relations, until the pencil pushers took over. That word was "Airmanship"

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11 minutes ago, jetjr said:

Insurers now ask all the same type of questions and cant handle the answer that all care was taken and it was a accident that no amount of preventative cost or analysis could forsee.

Maybe this is the continuation of safety at any cost mentality across lots of industries.

Its your responsibility to prevent accidents therefore if there is one its your fault.

There was no accident, and that wasn't by accident. An engine stoppage is required to be reported, even if it was just an annoyance.

Edited by M61A1

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21 minutes ago, jetjr said:

Insurers now ask all the same type of questions and cant handle the answer that all care was taken and it was a accident that no amount of preventative cost or analysis could forsee.

Maybe this is the continuation of safety at any cost mentality across lots of industries.

Its your responsibility to prevent accidents therefore if there is one its your fault.

Most people don't want to admit they screwed up.

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13 minutes ago, Yenn said:

It is not a continuation of safety at any cost.

It is a "Look how good we are at promoting safety"

Just another case of big noting themselves for a job very poorly done.

We used to have an appropriate word for human relations, until the pencil pushers took over. That word was "Airmanship"

It's not airmanship to fail to make a forced landing when the engine stops, in some cases above 1000 feet.

It's not airmanship to turn back and fail to make a landing when there are paddocks ahead.

It's not airmanship to kill yourself on the airfield boundary fence when you could have made a precautionary landing up to 30 minutes earlier.

It's not airmanship to take off after last light with a car headlight as your VFR aid, and kill yourself and the passenger who pleaded not to fly.

and so on.

If you genuinely practice airmanship you are less likely ever to be caught up in one of these discussions.

The reason the subject is debated is primarily because some organisations are appallingly bad at behavioural management.

Having said that there is also evidence that the majority of organisations have made their activities much safer.

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48 minutes ago, M61A1 said:

May I ask what you might have said?

I just ended up making sh1t up, so they would go away, as their suggestions were completely impractical as usual.

The follow up phone call was hardly encouragement to do another one should there be any further incidents.

Well you didn't actually specify what happened to you, so there's no point in me making something up.

I assume you had some sort of incident and submitted a factual report, but weren't happy with the follow up phone call?

 

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Yes a report was submitted. The follow up definately reeked of "box ticking". They just wanted something to fill the box, but the facts weren't good enough.

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