[Peetwo]

Ben Cook Part II & III - PelAir revisited.




The ditching of Australian aviation governance - Part 2

..When was the last time you did something that, in hindsight, you thought was foolish, stupid, not consistent with your normal behaviour, and possibly something that made you feel a little embarrassed about afterwards?

One of my experiences (a little over 20 years ago, but it only feels like yesterday) that left me feeling this way involved a big night out as part of a weekend flyaway that could have cost me, and my aviator mates, our careers.

Our mix of personalities, a not-so healthy combination of egos, and some environmental factors (alcohol) led to some very poor decision making. The outcome: one of the guys was going to drive a hire car off a long pier into the ocean!

The only reason this didn’t happen is the person who signed for the hire car was too worried they would be held accountable, so he wrestled the keys away from a very disgruntled pilot who was about to earn a pooled $500 from the other members of the
group. And we had a grand vision of waiting for the media with a beautiful sunrise and national stardom greeting us all.

It all sounds stupid in hindsight but it’s the power of personalities, eroded decision-making (via alcohol consumption) and an unnecessary acceptance of risk, which could have
resulted in permanently changed careers – or injury.

Yet this was a turning point for me to better understand the myriad of human factors that can quickly take us away from being the best we can be...

&..



Lessons from the Pel-Air ditching - Part 3

...Last issue we highlighted the significant impact fatigue can have on crews. In the case of Pel-Air Westwind ditching, the aircraft captain, having obtained only 3–3½ hours of average quality sleep, displayed a fixation on a simple plan to land. He and the remainder of the crew were too impaired to recognise growing evidence that the plan was not working. The flight nurse and doctor received minimal to no sleep during the day of the accident as they were too busy caring for the patient.

Even worse, the accident itself occurred on a remote island around 9.40pm, yet the crew were meant to be continuing from Norfolk Island to Sydney and then to Melbourne; well outside the acceptable limits of any mature fatigue risk management system (FRMS). This information has gained little attention even though it’s a clear example of failed company
processes and regulatory oversight.

The impact of elevated levels of fatigue is that people do not realise their level of impairment. They press on ‘lethargic and indifferent’ with a simple plan. This can occur in large organisations to even the most experienced crews...

Ben Cook & AA magazine initiative on fatigue: 

LEARN MORE ABOUT FATIGUE
written by Australianaviation.Com.Au May 11, 2018

In support of human factors expert Ben Cook’s feature article in the June issue of Australian Aviation, we have made available the following supporting documents:

• Fatigue investigation checklist: a simple checklist, as collectively developed by several civil and military organisations to provide enhanced guidance to determine whether fatigue contributed to the incident or accident. Download here
  
• Fatigue risk management chart: a list of some of the many factors that should be considered in determining whether fatigue risk is unacceptable. The chart is particularly good for personnel to better understand the main factors that influence fatigue. Download here
  
• A guide to a good night’s sleep: some extracts from a definitive book, A complete guide to a good night’s sleep, written by Dr Carmel Harrington, one of our local leaders in sleep science. The extracts provide practical insights from over 20 years of applied sleep science. Download here
  

Noted point of interest from this week's SBG: Minister for Reality – Really?

P2 comment - Read the Ben Cook PelAir Part 2 article here: The ditching of Australian aviation governance - Part 2

»» CASA’s procedures and guidance for scoping an audit included several important aspects, but it did not formally include the nature of the operator’s activities, the inherent threats or hazards associated with those activities, and the risk controls that were important for managing those threats or hazards.
»» Consistent with widely agreed safety science principles, CASA’s approach to conducting surveillance of large charter and air ambulance operators had placed significant emphasis on systems-based audits. However, its implementation of this approach resulted in minimal emphasis on evaluating the conduct of line operations (or ‘process in practice’).

Although there are pragmatic difficulties with interviewing line personnel and conducting product surveillance of some types of operations, such methods are necessary to ensure there is a balanced approach to surveillance, particularly until CASA can be confident that operators have mature safety management systems (SMSs) in place. [If CASA surveillance is too shallow how do more senior personnel (chief pilot, standards managers, check and training pilots) know whether their own practices are adequate and
aligned with best practice?]

Ultimately, inadequate regulatory oversight also contributed heavily to a false sense of security within Pel‑Air. How devastating it must have been post accident to have CASA inspectorate staff suddenly find so many systemic issues that had not been picked up during previous CASA surveillance.

Now watch again the '$89 million bucket' video (below). Anyone else get the impression there was no love lost between the former DAS McComic and BC 

 MTF...P2