[Peetwo]

P2 comment - Posted on behalf of P9 who was all thumbs and seven fingers when it came to initiating this new Forum - 

“For want of a nail the shoe was lost.”

“It's a dangerous business, Frodo, going out your door. You step onto the road, and if you don't keep your feet, there's no knowing where you might be swept off to.”

All day, every day, across this planet people travel; and, in one form or another, they use publicly available transportation. Bus, train, ferry, aircraft - all available for the cost of a ticket. Included within the price of that ticket is a high percentage chance that they will arrive at their destination. While that 'safe arrival' is not 100% guaranteed, mostly it is a very, very safe bet. Ever wonder why. If you ask around, you will receive many different answers, but only those involved in providing that transport know how much work and money and research and training (blood, sweat and tears) has gone into providing that singular service safe result. The real answer is in one word 'Reliability'. 

(Technology reliability) x (Human reliability) = System reliability.

Every mode of transport, from roller skates to space ships depends on system reliability to arrive at the destination in one piece. Many serious accidents have been the result of not only the failure of one element, but the events subsequent to that failure.

“For want of a shoe the horse was lost.”

Watching hours of Senate estimates is not a popular pastime; for example, when its my turn, I play it in the workshop and listen while I do something constructive; bit like the cricket on the radio. Mostly, the focus is on 'matters aeronautical' Canberra style, however as all methods of publicly available transport systems are all basically similar (in essence) almost any form of 'transport' event catches the attention; trucks, trains, boats and planes. Why, Well there is almost always a 'lesson' to be learned from every transport accident; and IMO they are, in principal at least, transportable. Human and system failures which lead to headlines.

“For want of a horse the rider was lost”

Once the 'headlines' are out there inevitably is an 'investigation and/or an 'inquiry' of some sort; aviation is famous for them (for some unknown reason). The investigation template in the aviation world mostly follows a well trodden pathway. When the return of that 'investigation' is serious; often some form of 'inquiry' is opened; and, that is when the 'fun' starts. The 'circuit breakers' are the first called in; they serve to protect the next level up the sheltered ladder of responsibility and are utterly disposable. If the powers that be persist with inquiry, the next layer in the protection racket is wheeled in and the dissembling and obfuscation begins in earnest – for they protect the ministerial appointment holders. They are wonderfully entertaining, masters of the  no accountability game; and, serve the 'system' very well and rewarded in kind. Which keeps everybody happy, except for the public who have forgotten and those left behind to wonder. Every aviation inquiry has, more or less, finished in the same manner, an instantly forgettable report which resolves very little. The top shelf defenders have learned where they are vulnerable to any hint of 'responsibility' and take the steps necessary to cover the gap. Bigger budget to generate more complex rules which relocate 'blame' and additional 'responsibility' to those outside the 'agency' while ensuring that in no way can 'they' ever be accountable or responsible. Its a game, played publicly, in the open and available on any Senate estimates 'you tube' session you care to sit through.

“For want of a rider the message was lost”

One of our crew stumbled on an Estimates session from the NSW division – related to the Sydney Harbour ferry system. Ships at sea and the men who manage the business are very closely related to those who manage aircraft. The parallels easily drawn; the legal responsibilities on par as are the penalties for any mismanagement. Two ships collide – the Masters are the people in the dock. However; the Skippers of ferries seem to have a problem that no aircraft pilot would tolerate. Should an aircraft have any form of 'control' problem (airborne or on the deck) there are back up systems and/ or alternate methods which may be used to ensure a safe return to land. Once on the ground, that aircraft would not move out of maintenance until the 'problem' had be 'properly' resolved; and, a report made; and, that report made available to the world wide fleet if the 'problem' was deemed systematic. But, it goes a little further; the aircraft would be 'Returned to Service' with a 'signature' of the person ultimately carrying the legally enforceable responsibility for the RTS. All documented and legally binding. The pilot scheduled to operate the aircraft signs a 'maintenance release' (again legally binding) fully aware of the repairs. It is an almost fool-proof system, with clearly defined lines of 'responsibility and accountability' all the way back to the CEO - ultimately.

“For want of a message the battle was lost”

Recently in the news (courtesy Matt O'Sullivan) the plight of the Masters of the Sydney ferry system has been brought to the attention of the public. Aunt Pru took an interest and we were off to the races. The first item of real interest was the closely guarded secret of just how many abnormal 'steering' events have actually occurred. (Give any pilot the screaming me-mi's). Once,  in any aircraft, would be enough. But not for the NSW government contractors; multiple loss of control events, the Masters (and the media) have forced the matter to the government attention - for action. We thought the antics of the aviation bureaucrats at Senate estimates were worthy of attention; but the NSW tribe beat the band, hands down. Below is a 'you tube' recording of the NSW estimates session. Click on at the 1 hour 56 second mark and watch carefully. These guys make the Canberra lot look like honest upright citizens; boy, they're good. Circuit breakers popping all the way back to the Minister, although, happily, his ultimate get out gaol card is 'the contract'.

The NSW state government seem to have several 'real' matters of transport safety to deal with. There are rumbles from within the Unions of those who actually operate the state's transport network. Trains and busses all with 'safety' matters which, (pardon the expression) should a wheel come off can only lead to more expense and embarrassment associated with 'accident', particularly if people are harmed or killed. But the one, easily definable 'safety issue' matter is a stand out example; that of the ferries which operate on Sydney harbour. Multiple steering failures; rumours of dodgy welding: AMSA getting involved, then not. Big bucks at stake if OTSI join hands with ATSB (etc.) – and yet the resident evil within the steering system of these large, high speed, passenger carrying vessels cannot be sheeted home and guaranteed, certified as rectified. What is it now 10, 15 – 20? incidents of failure; yet revenue and political denial of responsibility or accountability shy away from responsibility or accountability - eschewing centre stage (in Spades).

“For want of a battle the kingdom was lost”.

So, a new forum has been demanded by the BRB; one open to all 'drivers' of machinery which carries the fare paying public. Those who should be able to expect an equivalent level of operational reliability from a ferry, train, or even a humble bus as they are guaranteed when travelling by air. Imagine a bus with a steering problem; causing an accident making headlines for more than a day - unlikely. Then imagine that 10 steering failure related accidents occurring in a short space of time – what then? Aye; you imagine correctly. Bus carries what, 50 people; a ferry can carry 400 – and has a track record of provable 'steering failures'. Think on..Someone has to make certain that the basic of safety – reliability – is maintained. Just don't look to the political system support crowd to accept responsibility, be accountable or, better yet,  get the problem sorted.

Ramble over; but at the end of the shift, after the accident, when the knives come out, someone has to pay the freight. Last man standing is the driver, easy target, far removed from the machinations of 'deals' -  'contracts' and the zero responsibility/ accountability of the administration.

Toot toot.

Arrgggh! - Victimology – from plagiarised victim to idiot in one one fell swoop – I will repay.