Ben Cook and the Choc Frog award.
The Ben Cook article published in the Australian Aviation magazine is of great value in that it casts a wider net over the inherent contributing factors, the systematic failures and the lack of ‘real’ safety related oversight from the CASA, rather than safe, minimum compliance with ‘the law’.
Ben is a respected, acknowledged expert in his field of endeavour, the article reflects that expertise – from his point of view.
BC – "For many of us, we assume that CASA and the ATSB are the key players to make sense of the why in these types of accidents – that they will search for the root causes to ensure the broader aviation community can genuinely learn some lessons to prevent reoccurrence. Yet it appears this wasn’t the case for those aboard that medical evacuation flight in 2009.”
Your opinion depends of course on how ‘thorough’ and meticulous your own analysis of the incident has been and where and when the seeds of this accident were sown. For PAIN those seeds were sown with the Lockhart River tragedy. The abominable behaviour of both CASA and the ATSB before, during, after and since that event leaves much to be desired – from an operational safety point of view. The ATSB fall from excellence began with Lockhart. Many believe their ‘spirit’ was broken from then, routed, repressed and regressing to the pathetic ‘milk and water’ PR guff they provide today. The Pel-Air v1 and Pel-Air v2 reports stand testament to their shameful degeneration. ATSB should have drawn many of the same conclusions as Cook, the reports provided fail, dismally, to do so.
For some as yet unidentified reason, Dolan and McCormick embarked on a very risky journey, never expecting for one moment, that it would blow up to a Senate inquiry; well it did that and more. Had Cook and ‘operational’ expert opinion been sought in the beginning then a report of real safety value could have been produced and the disgrace which followed the Senate Inquiry could have been avoided – alas. But I digress.
Sandy raises some valid questions; the most obvious being why the amended weather forecasts were never received. That, in a nutshell is the final gaping hole in that famous Reason cheese. However, the Cook article tracks the chain of events back to Samoa; which is a reasonable starting place, but is it the right starting place?
I, for one, don’t believe it is. From an operational point of view one must dig a little deeper. For one small example of the many operational malfunctions which the CASA ‘experts’ failed, over a number of years to identify and correct, consider CFIT analysis. CFIT is a globally acknowledged killer; much hard work and expertise has been employed to reduce the risk. The Flight Safety foundation even provided a simple, highly effective tool, which, if used draws an operating crew to realise that their risk is elevated. When you run the analysis for the Norfolk flight, it clearly demonstrates an increased risk level of a CFIT event. Had the company procedures specified a ‘low’ and ‘high’ risk score and made it a requirement that a ‘high’ risk score demanded additional operational support - such as flight following or operational assistance on stand by; then, perhaps James may have been given a heads up on the changing weather conditions. There are many operational risk mitigation tools available to an operating company – beginning with clearly defined SOP which reflect realistic operational safeguards. Simple things like fuel planning requirements – how to; a fuel plan and ‘howgozit’ log, with CP and PNR calculations computed pre departure – amended as an where required to reflect actual operational conditions. Again, I wander.
Ben’s excellent article defines many of the background links in a long chain, very well. Certainly the ultimate ‘gotcha’ was the missing weather forecasts – but this accident began many, many moons ago.
I say the real investigation is yet to be done – ATSB and CASA have may questions to answer, the principal one being ‘what the hell were you playing at; and why? That’s before we take a long hard look at the facts of the Pel-Air audit and the speedy return to ‘normal’ operations. A close look at the ATSB second report is also on the cards; there are some questions there which demand satisfactory answers. Gods alone know how we are to get these questions asked and answered, with O’Sofullame at the helm of the Senate committee. No matter, we shall try.
Sandy – “The whole sorry saga of the botched investigations, with the suspected wink and nod between CASA and the then newly independent ATSB, has been muddied with assumptions and obfuscation.” Amen to that.
Nicely done Ben, second the Choc Frog nomination and look forward to the next.
Toot toot.
The Ben Cook article published in the Australian Aviation magazine is of great value in that it casts a wider net over the inherent contributing factors, the systematic failures and the lack of ‘real’ safety related oversight from the CASA, rather than safe, minimum compliance with ‘the law’.
Ben is a respected, acknowledged expert in his field of endeavour, the article reflects that expertise – from his point of view.
BC – "For many of us, we assume that CASA and the ATSB are the key players to make sense of the why in these types of accidents – that they will search for the root causes to ensure the broader aviation community can genuinely learn some lessons to prevent reoccurrence. Yet it appears this wasn’t the case for those aboard that medical evacuation flight in 2009.”
Your opinion depends of course on how ‘thorough’ and meticulous your own analysis of the incident has been and where and when the seeds of this accident were sown. For PAIN those seeds were sown with the Lockhart River tragedy. The abominable behaviour of both CASA and the ATSB before, during, after and since that event leaves much to be desired – from an operational safety point of view. The ATSB fall from excellence began with Lockhart. Many believe their ‘spirit’ was broken from then, routed, repressed and regressing to the pathetic ‘milk and water’ PR guff they provide today. The Pel-Air v1 and Pel-Air v2 reports stand testament to their shameful degeneration. ATSB should have drawn many of the same conclusions as Cook, the reports provided fail, dismally, to do so.
For some as yet unidentified reason, Dolan and McCormick embarked on a very risky journey, never expecting for one moment, that it would blow up to a Senate inquiry; well it did that and more. Had Cook and ‘operational’ expert opinion been sought in the beginning then a report of real safety value could have been produced and the disgrace which followed the Senate Inquiry could have been avoided – alas. But I digress.
Sandy raises some valid questions; the most obvious being why the amended weather forecasts were never received. That, in a nutshell is the final gaping hole in that famous Reason cheese. However, the Cook article tracks the chain of events back to Samoa; which is a reasonable starting place, but is it the right starting place?
I, for one, don’t believe it is. From an operational point of view one must dig a little deeper. For one small example of the many operational malfunctions which the CASA ‘experts’ failed, over a number of years to identify and correct, consider CFIT analysis. CFIT is a globally acknowledged killer; much hard work and expertise has been employed to reduce the risk. The Flight Safety foundation even provided a simple, highly effective tool, which, if used draws an operating crew to realise that their risk is elevated. When you run the analysis for the Norfolk flight, it clearly demonstrates an increased risk level of a CFIT event. Had the company procedures specified a ‘low’ and ‘high’ risk score and made it a requirement that a ‘high’ risk score demanded additional operational support - such as flight following or operational assistance on stand by; then, perhaps James may have been given a heads up on the changing weather conditions. There are many operational risk mitigation tools available to an operating company – beginning with clearly defined SOP which reflect realistic operational safeguards. Simple things like fuel planning requirements – how to; a fuel plan and ‘howgozit’ log, with CP and PNR calculations computed pre departure – amended as an where required to reflect actual operational conditions. Again, I wander.
Ben’s excellent article defines many of the background links in a long chain, very well. Certainly the ultimate ‘gotcha’ was the missing weather forecasts – but this accident began many, many moons ago.
I say the real investigation is yet to be done – ATSB and CASA have may questions to answer, the principal one being ‘what the hell were you playing at; and why? That’s before we take a long hard look at the facts of the Pel-Air audit and the speedy return to ‘normal’ operations. A close look at the ATSB second report is also on the cards; there are some questions there which demand satisfactory answers. Gods alone know how we are to get these questions asked and answered, with O’Sofullame at the helm of the Senate committee. No matter, we shall try.
Sandy – “The whole sorry saga of the botched investigations, with the suspected wink and nod between CASA and the then newly independent ATSB, has been muddied with assumptions and obfuscation.” Amen to that.
Nicely done Ben, second the Choc Frog nomination and look forward to the next.
Toot toot.