[Kharon]

Safety in mind: Normalisation of deviance

Remarkable debacles.



“You have power over your mind - not outside events. Realize this, and you will find strength.” ― Marcus Aurelius, Meditations


“K” comment: the temptation to tear this happy, clappy, PR guff and puff apart borders on the irresistible, however, the bucket will suffice. Who writes this fluffy stuff; the PR lady from Qantas? Its not even technically correct - retch.

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The ATSB has released the final investigation report into a flight path management occurrence involving a Boeing 737. The accident resulted in two crew members being injured and prompted Qantas to issue a safety information notice.

http://www.atsb.gov.au/newsroom/news-items/2018/qantas-takes-steps-to-improve-safety/ …

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It is rare that I break a promise – it happens – and this once I will do exactly that. The reason is that I was reading through the thread, to catch up and came across the ‘incident’ _HERE_. All the lights went on along with ‘Oh Bull-pooh’ meter going off the scale. Then my own comment – alas; but, in my defence M’lud, I ask you to read the following quotes from our ATSB investigation –
 
“At 22,000 feet, an abrupt change in the direction of the wind resulted in the aircraft airspeed increasing towards the maximum allowable operating speed.”


 
“The report also highlights the manufacturer’s preferred use of speed-brakes to prevent over speed. Boeing has advised that they are considering a revision to the over-speed guidance in the 737 flight crew training manual.”
 


I won’t go on about it – but, for a choc-frog – what’s wrong with these statements; yes, the tea lady may enter the competition. Total bollocks – PR spin – at great expense to the long suffering public. Enough.

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“I have never let my schooling interfere with my education.” ― Mark Twain

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Anyone else get the feeling that CASA are poised on the brink of actually grasping the realities of the unholy mess they have created? The big question is will the behemoth roll backward down the slippery slope to the swamps which spawned it; or, take a leap of faith toward sensible regulation? Time will tell – but its ‘time’ that is crucial. The money wasted is one sore point – but the time wasted is unforgivable. More time will go by now as matters aeronautical are pondered by folk who have no idea – time will be wasted while CASA try’s to unravel it’s knitting, time will go by as operators, once again redraft their operating protocols and procedures; more time will go by as CASA ‘approve’ (or accept) those manuals; time will go by as crew are trained or educated on the ‘new’ way of remaining legally ‘safe’.

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The Unreachables are they unteachable?

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Meanwhile – count on one hand the actual improvements, beneficial to industry, seen over the past five years. We must hope the ‘new’ minister does not renege on the deal Albo and Barmy-baby cobbled together and have the Act rewritten; they could also repeal the 1920’ s dinosaur which has been the catspaw of much evil intent.

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Speaking of evil intent, the Falcon Air story continues to dominate BRB discussions: for example:-
 
Q/ Carmody quote: "...The check on Mr James continued as we decided to deem it a private flight..."  - Besides the fact that there is many unexplained contradictions in the timeline, it would seem in the above quote that CC has tried to make it seem he was doing DJ favour by allowing the check to continue in a 'private' capacity - WTD??
 
P2 has provided the perfect example of CASA swinging a long line. Seriously, the spin and pony-pooh contained within the highlighted line defines CASA first XI methodology and spin bowling techniques. How for Pete’s sake can the flight be anything else – in law – but a ‘private’ flight – conducted as ‘Air-work’; one may also question, quite safely why there was a need for two CASA people to be on board. Seems to me there’s a ‘stretch’ of rules right there and a safety case.

Aye well; let’s all hope Carmody has been presented ‘all’ the facts and that those facts are ‘precise’. If they are not – he’s been placed in a hellish position – resignation being the only honourable escape – unless he fires, publically, those who may have cruelly deceived him and set him up to carry a large, smelly can. Time once again will provide the answers.

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“I did not attend his funeral, but I sent a nice letter saying I approved of it.” ― Mark Twain

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P2 – “The following is the relevant part of the report that caused this inquiry to be extended/deferred for 1 year:”
 
I wonder when one of the unintentional ‘victim’ groups is going to pipe up and get this airports inquiry swiftly moving in the right direction, you can feel a soupçon of sympathy for them and their insurance companies. Of all the ‘victims, they probably have more to loose than anyone else in the game. “Who?” – Oh, didn’t I say – well ‘tis the developers, the owners of the buildings and the big end of town investors. Bloody chancy thing to do – placing a building within a designated ‘safety zone’. CASA would have the world and his wife believe that the SZ is sacrosanct; and, up to a point this is true –but only at the departure and approach ends of a runway. There is a splay – a fan if you like – free of man made obstacles – above a certain height – within a certain distance; providing an ‘obstacle clear’ gradient. An area within which an aircraft with say an engine failure – flying ‘blind’ in cloud can be assured of not hitting anything – provided the aircraft can maintain the promulgated climb gradient. No one builds anything which penetrates the ‘safe’ area on the approach or the departure end of a runway. Not so the side safety zones. Essendon has a designated minimum runway width and associated ‘along side’ safety zones. Mr Peabody’s exemplary work shows, quite clearly, that the along side buffer zones were compromised to allow development which infringes those zones - there can be no argument – the pictures tell the tale.


Had the King-Air been a few feet lower and had the time of day been different and the Toy shop full of children and grown ups – no need to elaborate that; a fireball, multiple fatalities and years and years of court battles.




The political fallout immeasurable. Who would be the whipping boy? – Yep, you guessed, those with the most money. The insurance companies would go straight to the best chance of gaining compensation. Long winded way around the point I know – but I would imagine that ‘business’ would be making a submission to the Senate – just to cover their highly exposed rear ends. It’s a simple enough concept to grasp; don’t build within the runway safety zones – not even the along side zones. There’s still time – the Senate committee is moving at it’s customary speed; although what there  is to debate about clearly defined rules beats me.

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“Reader, suppose you were an idiot. And suppose you were a member of Congress. But I repeat myself.” ― Mark Twain

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Ah! There is the ‘toot-toot’ I’ve been waiting for – my lift to visit a timber yard – far, far away. Shopping, for blokes will fill the day in nicely, checks complete, DT happy; dogs done; stable tidy – Are we there yet??

 
Toot toot.