[Peetwo]

CASA & 'just culture'  - Fantasy or fact? 

Yes indeed this is an interesting one...

"K" said - Now Ben Sandilands over at Crikey has written an article on the PLANE Talking blog which is ‘interesting’ in that it mentions the CASA response to the incident.  Have a read of the ATSB report, then the article.  I can’t see why CASA would want to become embroiled in a prosecution, I can, just, see Ben’s point, but I fail to see anything of value other an expensive legal nightmare resulting from direct action by CASA – in this case.  
Anyway – FWIW, if time allows, have a scamper through both: personally, I think I may have to agree to disagree with Ben on this one.  Handing over.

This has also flowed through to the comments, with a bit of a ding dong going on between Fred & Ben.. :  

Ben Sandilands
3 hours ago

Fred, You've read the full report but somehow missed the safety message. Whatever the antecedents of a part, Cobham had to ensure the engine was repaired in accordance with the manufacturers procedures. They didn't. They are responsible for any consequences.



Dan Dair
1 hour ago

Does the ATSB report specifically say that they've trawled through all the previous owners documentation for this airframe & this specific engine.? How could Cobham's engineers weld-repair a combustion chamber wall without being fully aware of what the tolerances are for that repair.? Is it even appropriate to weld that area of the combustion chamber in that fashion.? Is there perhaps a repair plate which would include the welded boss so that the original weld is not being welded-over. (My limited experience of general (as opposed to aviation-grade) welding, is that the action of welding can make the surrounding area brittle & liable to cracking)


Fred 34 mins ago

Dan, Yes, the aircraft's past maintenance records were examined, but the records for the combustor housing only went back as far as 2005, when the housing was installed in the engine. There is no suggestion that Cobham's engineers were responsible for the errant weld-repair. If there was, then I'd imagine CASA would have plenty of grounds to pursue Cobham. According to the report, the last time that heavy maintenance took place was in 2009, before Cobham owned the aircraft. The investigators could not determine the timing of the dodgy repair from the maintenance records. There were three repairs, two of which only came to light through metallurgical analysis following the incident. One repair was documented properly and was performed in 2005, but the other two were undocumented and could have been done some time before or after 2005. According to the report, weld-repairs are approved by the engine manufacturer as a technique for repairing cracks in the combustor housing.

The problem, however, wasn't the weld; it was the grinding that was done afterwards that significantly reduced the thickness of the housing.


Fred

2 hours ago

Thanks for the condescending reply, but that still doesn't answer the question. In the real world, how was Cobham supposed to know that a dodgy repair had been performed on the engine? How could they possibly ensure the engine was repaired in accordance with the manufacturer's procedures if they had no way of knowing about the defect?

Dan Dair

59 mins ago

Fred,

I had this same conversation on the Virgin ATR "tail" incident pages.

It is apparent that, under Australian law, the airline and not the maintenance company, is primarily responsible for the condition of their aircraft.

That is not the way I had presumed it to be.

It remains the case that the maintenance company would be responsible in law for their failures, but the airline ultimately "holds the baby".


Fred

5 mins ago

Absolutely Dan, and I have no problem with that. But realistically, what would CASA achieve in terms of improving safety if it chose to pursue Cobham over a dodgy repair the company didn't perform and didn't know about? It gets back to that "just culture" thing. Ben said that a just culture is "supposed to be about protecting confidences in safety reporting", but that's only a small part of the story. A just culture was defined by James Reason as "atmosphere of trust in which people are encouraged (even rewarded) for providing essential safety-related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour". A just culture recognises that human beings are fallible and sometimes make mistakes. It encourages the open and honest reporting of such mistakes in order to improve the safety system, without fear of retribution. Nevertheless, it does not tolerate wilful misconduct.

In Cobham's case, it seems highly likely that this incident occurred through no fault of its own. If CASA pursued Cobham, it would send a very negative message to the industry. Nothing would be achieved in terms of improving safety outcomes and it would probably mean that other companies and individuals would think twice before reporting safety issues. Would that benefit the travelling public? I think not.

Mark Skinner
34 mins ago

Fred, the question should rather be whether or not Cobham could have seen the repair under the manufacturer's maintenance and inspection schedules.

If it could have seen/detected the repairs, then it is totally responsible, not only in law, but also morally. Because if it saw the repairs, but could not establish, for the reasons you pointed out, whether they were done correctly, then it should have had those repairs redone so that they COULD establish that they were done correctly.

The only out that Cobham might have morally is if those repairs were not detectable before the incident.

Perhaps Ben is overreaching with this one but again I think there are greater messages in here that are sadly being missed.
However first to this incident, IMO the best part about this report is that for once we are not talking about the ATSB - i.e. they have actually done their job and clearly stated the facts as presented...
For mine the key to this incident and the 'just culture' message is in the following passage from the Final Report:

In terms of Cobham Aviation Services Australia’s conduct of the most recent 500-hourly on-wing engine inspection, it was reasonable that, if the crack existed at that time, it was not visually-identified as:



• the crack was non-penetrating, meaning that it would probably have only been identifiable when the CTM was fully-disassembled (such as at a scheduled heavy maintenance inspection)



• there were no other, more usual, indications of a crack in the CTM, such as:



- increases in the engine condition trend monitoring data parameters



- blacking around any crack edges due to combusted gas leakage or fretting.



In addition to the lack of visual clues, the maintenance personnel were probably not expecting to find a crack. Human attention is guided by two factors:



• expectancy, where an individual will look where they expect to find information



• relevance, where an individual will look to information sources relevant to the important tasks and goals they need to carry out.



The key factor is expectancy. It is well demonstrated that people are more likely to detect targets when expected, and less likely to detect targets that are not expected (Wickens and McCarley, 2008). This occurs even when the targets are salient, potentially important and in an area to which the person is looking (Chabris and Simon, 2010).

We should also not overlook the 'safety actions' in response by the operator:

Cobham Aviation Services Australia



As a result of this occurrence, Cobham Aviation Services Australia (Cobham) undertook a number of safety actions to identify and capture defects of a similar type prior to their developing into an incident or accident. In addition, Cobham issued the following Technical Service Instructions (TSI):



• TSI-146-72-0015, issue 1 on 17 September 2014. This TSI stated that a detailed visual inspection for cracks was to be performed on each of the four combustion housing welded bosses across the Cobham fleet of ALF502R, LF507-1H and LF507-1F engines.

The compliance date for this TSI was 7 October 2014.



• TSI-146-72-0017, issue 1 on 21 April 2015. This TSI required a non-destructive Fluorescent Penetrant Inspection for cracks on each of the combustion housing welded bosses. This included the four combustion housing welded bosses, two drain valve bosses and the four igniter bosses on all of Cobham’s ALF502R, LF507-1H and LF507-1F engines. The compliance date for this TSI was 1 June 2015.



Cobham reported that of the 53 engines inspected, none had cracks in the location of the combustor housing combustion liner locating pin welded boss welds. However, seven previously-unidentified cracks were identified at the location of the ignition boss, which is also part of the combustor housing. Those cracks were routinely-managed in accordance with the manufacturer’s maintenance manual.

Now back to what is IMO the central issue to Ben's article that is now causing debate & contention in the ensuing commentary. 

First the background. Ben Sandilands has witnessed for many decades the administration of the Oz aviation safety system being manipulated, obfuscated, abused, historically tarnished, neglected etc..etc; by a rampant, seemingly untouchable bureaucracy that governments of either colour totally abscond from proper oversight or governance.

So naturally, like much of industry (refer ASRR report), Ben's trust quotient & 'bollocks' alert will be rapidly pinging when it comes to the regulator making comments like..

"...We also have system based on just culture to ensure open reports such as are made to the ATSB and mistakes rectified..."  

Until proven otherwise "just culture" & CASA in the same sentence will be met with much scepticism from an industry (including some aviation journos) that have been bullied, belittled, badgered and embuggerised by the "Iron Ring" big "R" regulator and supporting department for the best part of three decades...

Seaview...Lockhart...PelAir cover-up...Mildura Fog duck-up...VARA ATR bird strike abberration...the list & the bollocks continue - miniscule Chester please take note of what IMO is the most important part of Ben's article:

The new Minister Darren Chester is meeting the grass roots aviation industry in Tamworth this Friday, one hopes before the government goes into caretaker mode on the calling of a general election.

It is an important meeting. It is also important for the Minister to note that his predecessors were treated with arrogant contempt by his department in relation to aviation matters and public safety, and that taking visible control of his portfolio and remembering he is a representative of the people, not unaccountable bureaucrats or corporate entities, is a prerequisite for being held in respect.

 

MTF...P2

Ps

VH-NJI in-flight fire damage



Source: Jason Grimmett

Gotta wonder where all those bits happened to land -