Probability, Probity, Prosecution, Prevention and Cure.
Back to the 'Middle Beach' event; not my choice, the BRB decided to have a 'chat' about the 'back-room' blow - those surrounding the event and the ruthless prosecution of the pilot.
..”The ATSB recently noted limitations with CASA’s surveillance processes of charter operators during the period up to 2009 in its AO-2009-072 (reopened) investigation report (released in November 2017).
That comment almost gives the game away; “noted limitations with”. Etc”. It depends on who and how that is being read and translated; but – it begs the question – is CASA only interested in the 'legal' arguments which could come back at them?. In short, what did they miss or not understand related to 'operational matters'. If one has no 'experience' of a specific type of operation, then the chances are that 'something' which could cause 'trouble' has been missed – by the alleged 'expert' CASA crew.
ATSB - “It concluded there was a safety issue at that time with the procedures and guidance for conducting surveillance events not formally including the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards”. (Amen to that)....
The underpinning logic in that adroitly framed nonsense is, like dog's balls, easy to spot from the rear view. However, it does reinforce the notion that those doing the 'surveillance' failed to identify the inherent risks associated.
ATSB - “With the introduction of the CASA Surveillance Manual in 2012, there appeared to be no additional guidance procedures or guidance that addressed this issue. A review of the available evidence associated with the surveillance of Wyndham Aviation suggests that this safety issue still existed in practice during the period up to 2017”...
No surprises there - to amend 'procedure' opens a crack for a smart defence, any admission of CASA 'missing' a 'safety element' sends shivers through the prosecution. That element, stand alone, goes part way to explaining the ferocious, unrelenting prosecution of the pilot conducting the 'operation' at Middle Beach, which claimed a life.
Original comments - HERE-.
But, what of 'risk' ? There are literally mountains of analysis, pro and con, written on the subject and the satellites of safety matrix and its diaspora of prophets; all 'expert' – all trying to win a hand against 'fate' – or Murphy. Take our seemingly simple aviation operation at Middle Beach – a 'joy – flight' – an adventure flight – a 'Thrill flight' – call it what you will; but, at the end of the shift, it is nothing more than a routine operation, as conducted across the globe by countless pilots almost on a daily basis (or week-ends). The 'risk' matrix can be broken down into a few very basic areas of 'high' risk. It is within the identification of those risks and the strategies in place to minimise both the obvious and more 'subtle' risks that the 'problems' reside. The essential elements are 'who' evaluates that risk and the risk to 'them' for making that evaluation; the level of actual risk involved in the proposed operation; and the attitude of those conducting that operation toward the 'allowed' level of risk.
If we set aside the 'legal' risks involved in the conduct of 'beach landing joy flights' for a moment, for they are well and truly understood and carved in stone as part of 'operational approval'; we are left with the innocent public signing up for the 'experience'. For them, it is all a bit like a visit to the Disney Land rides; or the Big Dipper etc. There is a certain 'thrill' to be had; the option for screaming is almost mandatory and no permission is required to throw up. It is all part and parcel of a 'thrill' ride. Yet, folk do get hurt, there has been the odd death recorded, but have 'operators' been prosecuted; unless there is a gross breach of the stated 'safety parameters'. Investigated, thoroughly no doubt, which is a correct thing to do with injury of death. Yet folks still queue up all the same for the 'ride of a lifetime'. It is pretty much the same for the 'thrill flight' punters; would an 'ordinary' joy flight attract the same numbers – once around the island and home for tea? So do we have 'risk aware' punters or, is there a need to point out that the flight has perils? If so, then we need to quantify the risk matrix: percentage chance of a high risk (life threatening) event occurring: the percentage chance of a real emergency (Mayday call); same for a partial problem (Pan call) and the percentage chance of a re-portable occurrence.
Easily done – Single engine hours operated : engine failures. Say 2000:1 just for a number, same-same for accident on landing with commercial pilots – what, say 1500:1; crash on beach landings with experienced crew after conducting strip inspection; what, call it about 100,000 :1. Then quantify the risk of engine failure at low level on a go around after a beach inspection with little in the way of time or wriggle room available – the odds against are astronomical. Ignore my 'made up' numbers, but consider the chances of the combination at Middle Beach occurring. Pretty long odds for a betting man offered on the chance of a repeat.
But I will stand behind this bit: if you were not there then how can you possibly expound what could/ should have been done. To investigate is righteous; but to prosecute (criminal) on the 'evidence' available is, IMO, a step too far and a stretch to the giddy limits of innocent until proven guilty. Has CASA drafted a rule set or tailor made prescription as part of the Company operational approval, detailing a procedure and training regime for engine failure at/ or below 200' - on go around - with little to no options for a landing area? Then what right do they have for prosecuting the Mutt caught in that situation?
Right I'll shut up now; bloody rain is keeping me indoors when I need to be out and doing. Makes me cranky and bored; not a good combination.
Toot – toot.
Back to the 'Middle Beach' event; not my choice, the BRB decided to have a 'chat' about the 'back-room' blow - those surrounding the event and the ruthless prosecution of the pilot.
..”The ATSB recently noted limitations with CASA’s surveillance processes of charter operators during the period up to 2009 in its AO-2009-072 (reopened) investigation report (released in November 2017).
That comment almost gives the game away; “noted limitations with”. Etc”. It depends on who and how that is being read and translated; but – it begs the question – is CASA only interested in the 'legal' arguments which could come back at them?. In short, what did they miss or not understand related to 'operational matters'. If one has no 'experience' of a specific type of operation, then the chances are that 'something' which could cause 'trouble' has been missed – by the alleged 'expert' CASA crew.
ATSB - “It concluded there was a safety issue at that time with the procedures and guidance for conducting surveillance events not formally including the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards”. (Amen to that)....
The underpinning logic in that adroitly framed nonsense is, like dog's balls, easy to spot from the rear view. However, it does reinforce the notion that those doing the 'surveillance' failed to identify the inherent risks associated.
ATSB - “With the introduction of the CASA Surveillance Manual in 2012, there appeared to be no additional guidance procedures or guidance that addressed this issue. A review of the available evidence associated with the surveillance of Wyndham Aviation suggests that this safety issue still existed in practice during the period up to 2017”...
No surprises there - to amend 'procedure' opens a crack for a smart defence, any admission of CASA 'missing' a 'safety element' sends shivers through the prosecution. That element, stand alone, goes part way to explaining the ferocious, unrelenting prosecution of the pilot conducting the 'operation' at Middle Beach, which claimed a life.
Original comments - HERE-.
But, what of 'risk' ? There are literally mountains of analysis, pro and con, written on the subject and the satellites of safety matrix and its diaspora of prophets; all 'expert' – all trying to win a hand against 'fate' – or Murphy. Take our seemingly simple aviation operation at Middle Beach – a 'joy – flight' – an adventure flight – a 'Thrill flight' – call it what you will; but, at the end of the shift, it is nothing more than a routine operation, as conducted across the globe by countless pilots almost on a daily basis (or week-ends). The 'risk' matrix can be broken down into a few very basic areas of 'high' risk. It is within the identification of those risks and the strategies in place to minimise both the obvious and more 'subtle' risks that the 'problems' reside. The essential elements are 'who' evaluates that risk and the risk to 'them' for making that evaluation; the level of actual risk involved in the proposed operation; and the attitude of those conducting that operation toward the 'allowed' level of risk.
If we set aside the 'legal' risks involved in the conduct of 'beach landing joy flights' for a moment, for they are well and truly understood and carved in stone as part of 'operational approval'; we are left with the innocent public signing up for the 'experience'. For them, it is all a bit like a visit to the Disney Land rides; or the Big Dipper etc. There is a certain 'thrill' to be had; the option for screaming is almost mandatory and no permission is required to throw up. It is all part and parcel of a 'thrill' ride. Yet, folk do get hurt, there has been the odd death recorded, but have 'operators' been prosecuted; unless there is a gross breach of the stated 'safety parameters'. Investigated, thoroughly no doubt, which is a correct thing to do with injury of death. Yet folks still queue up all the same for the 'ride of a lifetime'. It is pretty much the same for the 'thrill flight' punters; would an 'ordinary' joy flight attract the same numbers – once around the island and home for tea? So do we have 'risk aware' punters or, is there a need to point out that the flight has perils? If so, then we need to quantify the risk matrix: percentage chance of a high risk (life threatening) event occurring: the percentage chance of a real emergency (Mayday call); same for a partial problem (Pan call) and the percentage chance of a re-portable occurrence.
Easily done – Single engine hours operated : engine failures. Say 2000:1 just for a number, same-same for accident on landing with commercial pilots – what, say 1500:1; crash on beach landings with experienced crew after conducting strip inspection; what, call it about 100,000 :1. Then quantify the risk of engine failure at low level on a go around after a beach inspection with little in the way of time or wriggle room available – the odds against are astronomical. Ignore my 'made up' numbers, but consider the chances of the combination at Middle Beach occurring. Pretty long odds for a betting man offered on the chance of a repeat.
But I will stand behind this bit: if you were not there then how can you possibly expound what could/ should have been done. To investigate is righteous; but to prosecute (criminal) on the 'evidence' available is, IMO, a step too far and a stretch to the giddy limits of innocent until proven guilty. Has CASA drafted a rule set or tailor made prescription as part of the Company operational approval, detailing a procedure and training regime for engine failure at/ or below 200' - on go around - with little to no options for a landing area? Then what right do they have for prosecuting the Mutt caught in that situation?
Right I'll shut up now; bloody rain is keeping me indoors when I need to be out and doing. Makes me cranky and bored; not a good combination.
Toot – toot.