Embuggerance Noose v Safety loop.
There will be many who think the latest foray by CASA into the AAT arena was ‘something-nothing’; there will be others who think the rules were broken by an individual who was rightfully punished for doing so; then there is the BRB who simply ask the questions – what was the safety outcome? Who benefited from the cost of the exercise? Was the safety loop closed? I'll try to keep it short:-
It could be argued ‘black letter’ law was broken; and, indeed it was – several times, according to the evidence provided. CASA patiently gathered evidence to support a ‘safety case’ then rather than prosecute the case, decided not to take it any further but waited then knocked back an application for an appointment, based against untested ‘facts and circumstances’ at a later date.
Do you see any benefit, to industry safety, from this course of action? Any at all.
As far as we can tell, when the accused was CP he was ‘slack’ with the paperwork; to wit, the Fuel on Board (FoB) at start should be recorded; the flight time should be recorded and the FoB at shutdown should be recorded. This is not only a world wide practice, but an important operational necessity. Much depends on the accuracy of these figures, operationally and legally. Payload and performance data is based against ‘weight’, there have been several instances quite recently where heavy jet transport have had ‘incidents’ simply because the wrong data was used for calculation. So, is recording the FoB status critical to safety? Yes, is the short answer.
One of the allegations made centres on the ‘weight and balance’ calculations – ‘the trim’. Aircraft have what is known as a centre of gravity (CoG) envelope. It has been proven, many times, that recklessly operating outside of the envelope limitations is dangerous; often fatally so. It’s a pretty fair bet that most professionals have experienced operating with a CoG on the raggedy edges and vowed never to let it happen again. This is particularly important when the CoG is not returning to within the ‘envelope’ as fuel is burned off; in some situations, as the fuel weight diminishes, the CoG can move further away from a critical limit, which is seriously dangerous stuff.
If one forgets about ‘law’ for a moment and considers the operational risk; the case for beating the importance of these calculations into the wooden heads of junior pilots becomes clear; the reasons for refusing to operate outside of theses tolerance ever clearer. It is truly essential. When there has been an incident or accident, the first things determined are the fuel status and CoG location. This can be calculated from recorded figures. When the time comes for sheeting home ‘blame’ (read liability) the fact that the aircraft was legally loaded and trimmed becomes pivotal.
Right, banged on about that enough, lets get down to brass tacks. The big question the BRB want answered is what the hell was CASA playing at?
Here we have an almost classic case of ‘normalised deviance’. Easy to understand; and not, standing alone, terribly dangerous – operationally. The R 22 range of CoG movement with fuel burn off is limited to a very narrow band; so narrow as not to be worthy of serious consideration – as a 'safety' (not legal) matter. The adding and subtracting of 10 or 20 litres of fuel insignificant to operational safety range –
for that aircraft. For an experienced man, operating in the bush on say mustering duties the notion of doing a CoG calculation for every flight would never enter his head; quite right too. But in a flight training operation, where the foundations of future operating practice are laid, not to do so would be a serious matter. Yes, it’s bloody tedious; weighing stuff, calculating the fuel burn, working out the payload, take off weight, landing weight, checking the graphs etc. But it is, at flight school level an essential element. CASA happily testify that they sat back and allowed several counts of a clearly defined, normalised deviance to occur – and did nothing. How many students now have a cavalier attitude toward these matters, because it was allowed to run on? More to the point; if CASA became aware of the practice, then why was the accused not taken aside, spoken to then monitored to make sure the message had been 'properly' delivered?.
Why then, if the practices prosecuted are so lethal and dangerous were they allowed to be continued until a case could be built. The reasons are obvious; there was a case for a serious chat and blood curdling threats to be made; but without a ‘history’ to support the case, CASA had nothing to work with. Dangerous (CASA says) practice allowed to continue, rather than intervention and education. BRB rules that CASA were much more likely to be the root cause an accident than the accused; they knew and failed to act in a proactive manner. Guilty, so say we all. Wotherspoon certainly needed his arse kicked, that’s why CASA have the big boots. Had they done so and the practice continued, then I would say prosecute and well done. But to lay in wait, building a ‘case’ over a period of time, while ignoring the ‘real’ safety issues smacks not only of vendetta, but dereliction of duty.
Do we have any benefit to industry from this very, very expensive exercise?
Would industry have been better served by quick, immediate action followed by a briefing in the CASA magazine, warning, yet again of the perils of overweight out of CG operations. Perhaps not, but it would have achieved more for ‘safety’ than this fatuous affair in the AAT.
Has the ‘safety loop’ been closed on this issue, through CASA actions?
No, it has not. CASA have failed, yet again, to get the message through to the general population. Until it is understood why these calculations are important; there is no real deterrent or benefit provided.
What, in seven hells is Carmody going to do about it all?
Ayup, you guessed it – SFA. He and bureaucrats like him don’t see the disparity between CASA actions over several cases, that alone is risible. But the continued, selective, subjective, vindictive, pointless edicts of the self appointed judge, jury and executioners is one of the real root cause of industry problems with the CASA. Consistency of action and safety values matter to all, except to those who rely on those elements to weave their little plots and gain brown-eye points. Disgusting.
Reform of the regulator is paramount - just can’t see Carmody tackling that beast. Brains, balls and good will are required; all in short supply at Sleepy Hollow.
Selah.
Sorry P7 – I’ll keep the tote running, but SFA is the only entry so far; Negligence and Ineptitude are in training, Malice and Aforethought can’t decide on a rider and Vindictive is waiting on the Vet’s advice. Patience mate, patience.