Perseverating :: Perspicacity :: Self preservation?
As mentioned, there was an 'uproar' at the last BRB indaba. I thought (FWIW) it may be worthwhile to 'boil down' my notes and try to frame, in a short 'blurb' the radical cause of such concern. When qualified, competent, even considered 'experts' start to boil over, time to simmer the pot. The short version is in the heading; and, the conflicts it all creates.
Perseveration is demonstrated by the inability to shift from one concept to another or to change or cease a behaviour pattern once having started it. Perseveration also refers to the inability to translate knowledge into action (initiation of a task). The person is “stuck in set”—unable to discard the previous set of behaviours—or is unable to “activate” for a new situation. The person stuck in set attempts to solve another problem with information relevant to a previous problem.
If there is a 'logical' start point, I think ICAO would be a good place to begin. The 'crew' had taken a long, hard look at the pertinent documents, from the perspective of our State Safety Program (SSP) performance. Their opinion was rather than focus on our apparent regulatory differences (there's more non-compliance than compliance), the following observations regarding our Aircraft Accident Investigation (AAI) obligations of our SSP, undertaken by the ATSB were made and supported.
ICAO 2016 SMICG SSP/SMS recommendations (co-authored by CASA) state:
"1.3 — Accident and Incident investigation.
(a) Consider the contribution and function of the State accident investigation body to the SSP, especially to your safety risk and mitigation actions.
(b) There needs to be organisational independence between the State accident investigation body and State authorities; however, there does need to be an interrelationship within the SSP."
The Helibrook and SeaWorld helicopter accidents are current / prime examples of complex activities involving all aspects of the ’system'. The ICAO 2019 SMICG document titled; “Safety Case Evaluation” (co-authored an by CASA), is at the core of these accidents, yet not discussed or bench-marked in the ATSB ’s reports. The Safety Case Evaluation states:
"Regulatory requirements.
Regulatory Authorities may require a formal safety case to be submitted in certain instances such as change management or addressing specific safety issues. There may also be specific regulatory requirements on how a safety case or safety risk assessment is formally accepted on the basis of existing regulatory obligations. These should always be followed, and this guide supports that formal acceptance.
This guide should be used to record the Regulatory Authority’s evaluation of a safety case in order to demonstrate that the safety case was appropriately evaluated by the Regulatory Authority."
Both accidents involve changes from approved operations: (Helibrook HEC) and (SeaWorld RHS > LHS, A/C change) - a significant shift in operational configuration. The guidelines discuss ‘regulatory involvement’ in change management and highlight the consideration of:_
"what confidence the regulator has with the operator making the change?"
Considering Helibrook had a history of several prior incidents and a (known) unimplemented SMS (2019); what confidence level did CASA have to issue the HEC Approval (multiple times)? Additionally, the repeated Approval renewal appears to be influenced by the instrument expiration and upcoming crocodile egg collecting season (FOI documents). This is relevant contextual information that should be appropriately disclosed in a ’systemic’ investigation. Also, the 2019. Level 1 CASA Systems Audit, had identified that the Helibrook SMS was NOT implemented. As a ’Systemic’ investigation, lessons from the performance of the SMS, prior to he accident, would be valuable to the industry. A missed opportunity by the ATSB? (Silly question department - init).
ICAO guide outlines 6 Steps in a Safety Case Evaluation guide. Of particular note is Step 2. It lists specific instructions and evaluation guidance with system change. With these accidents in-mind, it’s worth reading the ICAO recommended process - it makes a lot of basic sense and therefore should form part of the ATSB ’s analysis.
In the SeaWorld (‘Defined’) accident with changes requiring the PIC to occupy the LHS; new visual patterns/perspectives were introduced. These represent a significant change and a Safety Case should have been triggered within their ‘accepted' SMS. Subsequently, that should have been evaluated by CASA.
Anyone who’s ever adapted to a left-hand drive car understands the issues - it’s not rocket science and the variety of risks are tangible. Considering this was a high frequency - rapid, short rotation - high traffic density - passenger operation, there would be a lot to learn. It has potential valuable SMS lessons and an insight into procedural design change challenges (comms/circuit design/SOPs etc).
This detail isn’t available in the ATSB Interim report - a year after the accident. To date, we have an ATSB PR Brief and Interim report that chose to disclose, amongst a myriad of contributory factors, that the PIC of one A/C had very low traces of a prohibited substance that, according to a forensic pharmacologist, would have been unlikely to have had any psycho motor skill impairment. This was scripted and disingenuous in the general view. But, needless to say, the media jumped aboard and embellished this non-contributory fact, as blame (bugger research). The ATSB would be best served to dump its PR strategy as the media don’t understand ’no-blame’, nor do the majority of the public, so it's a pointless exercise.
Similarly, the Helibrook (‘Systemic') investigation should have had a thorough assessment the Approval application (triggering a Safety Case) and CASA should have evaluated a new application - EVERY YEAR. Grudgingly, the crew gave credit to the ATSB for at least partially analysing the history of the Approval process, albeit only part of the process. A broader view of historical organisational surveillance would be informative in understanding the accident context.
Noticeably, a CASA Board meeting was held in DRW June 2021 and the upcoming HEC restrictions were to be discussed, followed by a demonstration flight with Helibrook. Did this influence CASA’s confidence in the operation and/or HEC Approval in September 2021? It’s not included in the ATSB report, for whatever reason - and I’m sure it’s not a good one. The CASA ‘Gift Register’ financial declaration satisfies disclosure and transparency, yet perception of conflict is often worse than an actual conflict itself. Regardless of the level of influence the Board meeting had, it’s relevant factual context that should have be disclosed in the analysis.
Step 5 in the ICAO Safety Case Evaluation process is: 'Risk Mitigation and Acceptance'. Again, its worth keeping these accidents in-mind whilst reading this guidance:
With the Helibrook accident, thorough analysis of this guidance may have identified why and how CASA ’‘drifted’ from the 2013 Risk Management Plan (RMP) position? All the ATSB have established is that it happened. Identifying process improvement appears to be received with derogatory connotations by SSP agencies rather being seen as opportunities to improve.
Whether the ATSB is suffering from ministerial capture, bureaucratic pressure or individual self-preservation, it needs to change and comply with the intent of ICAO Annex 13. When you take into consideration other aspects of the SSP, ie, ATC, Aerodromes, ATSB KPI’s, CASA oversight etc, we (AUS) are ‘flying dangerously’.
A SSP, as with any safety system, requires compliance with SOP's and risk management to maintain a safe baseline performance. The various agencies of our SSP hold the industry accountable to these obligations, yet deviations/interpretations within the SSP seem to go unopposed, or worse, remain as latent conditions. The 'no-blame’ ATSB agency must be empowered to provide constructive criticism relating to SSP deviations -in a mature system, it is expected. These were both fatal accidents that must be learnt from.
All, simply closed off with ICAO’s statement. "It is important to recognise that an SSP is an activity and not just a document” (Shelf-ware). Our SSP has large agencies with very detailed bureaucratic processes, yet the 'outcome' doesn’t functionally address the intent of the SSP. There appears to be unbalanced ‘authority gradients’ within our SSP.
There was more, much more, but, in essence, the above paraphrases a collective opinion, (without the 'sound and fury'). But IMO, the 'big question has not as yet been answered. When are the grown ups going to turn up and 'audit' DoIT supervision of 'system' ? Use their Perspicacity to prevent further Perseverating and ensure the Self preservation of the Australian travelling public and the industry which carries it. Time: Gentlemen PLEASE..!
Toot -(weary) - toot......
As mentioned, there was an 'uproar' at the last BRB indaba. I thought (FWIW) it may be worthwhile to 'boil down' my notes and try to frame, in a short 'blurb' the radical cause of such concern. When qualified, competent, even considered 'experts' start to boil over, time to simmer the pot. The short version is in the heading; and, the conflicts it all creates.
Perseveration is demonstrated by the inability to shift from one concept to another or to change or cease a behaviour pattern once having started it. Perseveration also refers to the inability to translate knowledge into action (initiation of a task). The person is “stuck in set”—unable to discard the previous set of behaviours—or is unable to “activate” for a new situation. The person stuck in set attempts to solve another problem with information relevant to a previous problem.
If there is a 'logical' start point, I think ICAO would be a good place to begin. The 'crew' had taken a long, hard look at the pertinent documents, from the perspective of our State Safety Program (SSP) performance. Their opinion was rather than focus on our apparent regulatory differences (there's more non-compliance than compliance), the following observations regarding our Aircraft Accident Investigation (AAI) obligations of our SSP, undertaken by the ATSB were made and supported.
ICAO 2016 SMICG SSP/SMS recommendations (co-authored by CASA) state:
"1.3 — Accident and Incident investigation.
(a) Consider the contribution and function of the State accident investigation body to the SSP, especially to your safety risk and mitigation actions.
(b) There needs to be organisational independence between the State accident investigation body and State authorities; however, there does need to be an interrelationship within the SSP."
The Helibrook and SeaWorld helicopter accidents are current / prime examples of complex activities involving all aspects of the ’system'. The ICAO 2019 SMICG document titled; “Safety Case Evaluation” (co-authored an by CASA), is at the core of these accidents, yet not discussed or bench-marked in the ATSB ’s reports. The Safety Case Evaluation states:
"Regulatory requirements.
Regulatory Authorities may require a formal safety case to be submitted in certain instances such as change management or addressing specific safety issues. There may also be specific regulatory requirements on how a safety case or safety risk assessment is formally accepted on the basis of existing regulatory obligations. These should always be followed, and this guide supports that formal acceptance.
This guide should be used to record the Regulatory Authority’s evaluation of a safety case in order to demonstrate that the safety case was appropriately evaluated by the Regulatory Authority."
Both accidents involve changes from approved operations: (Helibrook HEC) and (SeaWorld RHS > LHS, A/C change) - a significant shift in operational configuration. The guidelines discuss ‘regulatory involvement’ in change management and highlight the consideration of:_
"what confidence the regulator has with the operator making the change?"
Considering Helibrook had a history of several prior incidents and a (known) unimplemented SMS (2019); what confidence level did CASA have to issue the HEC Approval (multiple times)? Additionally, the repeated Approval renewal appears to be influenced by the instrument expiration and upcoming crocodile egg collecting season (FOI documents). This is relevant contextual information that should be appropriately disclosed in a ’systemic’ investigation. Also, the 2019. Level 1 CASA Systems Audit, had identified that the Helibrook SMS was NOT implemented. As a ’Systemic’ investigation, lessons from the performance of the SMS, prior to he accident, would be valuable to the industry. A missed opportunity by the ATSB? (Silly question department - init).
ICAO guide outlines 6 Steps in a Safety Case Evaluation guide. Of particular note is Step 2. It lists specific instructions and evaluation guidance with system change. With these accidents in-mind, it’s worth reading the ICAO recommended process - it makes a lot of basic sense and therefore should form part of the ATSB ’s analysis.
In the SeaWorld (‘Defined’) accident with changes requiring the PIC to occupy the LHS; new visual patterns/perspectives were introduced. These represent a significant change and a Safety Case should have been triggered within their ‘accepted' SMS. Subsequently, that should have been evaluated by CASA.
Anyone who’s ever adapted to a left-hand drive car understands the issues - it’s not rocket science and the variety of risks are tangible. Considering this was a high frequency - rapid, short rotation - high traffic density - passenger operation, there would be a lot to learn. It has potential valuable SMS lessons and an insight into procedural design change challenges (comms/circuit design/SOPs etc).
This detail isn’t available in the ATSB Interim report - a year after the accident. To date, we have an ATSB PR Brief and Interim report that chose to disclose, amongst a myriad of contributory factors, that the PIC of one A/C had very low traces of a prohibited substance that, according to a forensic pharmacologist, would have been unlikely to have had any psycho motor skill impairment. This was scripted and disingenuous in the general view. But, needless to say, the media jumped aboard and embellished this non-contributory fact, as blame (bugger research). The ATSB would be best served to dump its PR strategy as the media don’t understand ’no-blame’, nor do the majority of the public, so it's a pointless exercise.
Similarly, the Helibrook (‘Systemic') investigation should have had a thorough assessment the Approval application (triggering a Safety Case) and CASA should have evaluated a new application - EVERY YEAR. Grudgingly, the crew gave credit to the ATSB for at least partially analysing the history of the Approval process, albeit only part of the process. A broader view of historical organisational surveillance would be informative in understanding the accident context.
Noticeably, a CASA Board meeting was held in DRW June 2021 and the upcoming HEC restrictions were to be discussed, followed by a demonstration flight with Helibrook. Did this influence CASA’s confidence in the operation and/or HEC Approval in September 2021? It’s not included in the ATSB report, for whatever reason - and I’m sure it’s not a good one. The CASA ‘Gift Register’ financial declaration satisfies disclosure and transparency, yet perception of conflict is often worse than an actual conflict itself. Regardless of the level of influence the Board meeting had, it’s relevant factual context that should have be disclosed in the analysis.
Step 5 in the ICAO Safety Case Evaluation process is: 'Risk Mitigation and Acceptance'. Again, its worth keeping these accidents in-mind whilst reading this guidance:
With the Helibrook accident, thorough analysis of this guidance may have identified why and how CASA ’‘drifted’ from the 2013 Risk Management Plan (RMP) position? All the ATSB have established is that it happened. Identifying process improvement appears to be received with derogatory connotations by SSP agencies rather being seen as opportunities to improve.
Whether the ATSB is suffering from ministerial capture, bureaucratic pressure or individual self-preservation, it needs to change and comply with the intent of ICAO Annex 13. When you take into consideration other aspects of the SSP, ie, ATC, Aerodromes, ATSB KPI’s, CASA oversight etc, we (AUS) are ‘flying dangerously’.
A SSP, as with any safety system, requires compliance with SOP's and risk management to maintain a safe baseline performance. The various agencies of our SSP hold the industry accountable to these obligations, yet deviations/interpretations within the SSP seem to go unopposed, or worse, remain as latent conditions. The 'no-blame’ ATSB agency must be empowered to provide constructive criticism relating to SSP deviations -in a mature system, it is expected. These were both fatal accidents that must be learnt from.
All, simply closed off with ICAO’s statement. "It is important to recognise that an SSP is an activity and not just a document” (Shelf-ware). Our SSP has large agencies with very detailed bureaucratic processes, yet the 'outcome' doesn’t functionally address the intent of the SSP. There appears to be unbalanced ‘authority gradients’ within our SSP.
There was more, much more, but, in essence, the above paraphrases a collective opinion, (without the 'sound and fury'). But IMO, the 'big question has not as yet been answered. When are the grown ups going to turn up and 'audit' DoIT supervision of 'system' ? Use their Perspicacity to prevent further Perseverating and ensure the Self preservation of the Australian travelling public and the industry which carries it. Time: Gentlemen PLEASE..!
Toot -(weary) - toot......