[Peetwo]

Shot down in flames: the dangers of the blame game.  (Retch - gag)..

The article – HERE – from CASA – Flight Safety makes some valid points; but it’s a bit rich – considering the CASA track record for pilot embuggerance.  Could it be the ultimate in CASA hypocrisy?  

Perhaps it’s a subtle attempt to turn down the heat CASA rightfully attracts through social media.  There really is no other way to expose the inane antics, cock-ups and pure bastardy of the CASA culture, the evidence stacking, the underhand, disingenuous methods employed, when CASA decide to go after a pilot.  There is no other avenue and when you analyse the CASA tactics you realise that there no depth they will not plumb to prove that they were right.  Reprisals, flimsy, subjective NCN parlayed into heinous crimes against safety, some companies feted and favoured, others moving targets.  Vendetta, pay-back, etc. and CASA is now all gooey eyed and PC, begging pilots not to gang up on each other, while the CASA fifth column are texting and whispering to their CASA sponsors – bollocks.

No matter – there are some valid points made – not that they will change anything, but it’s good to know – CASA cares.

Physician – heal thyself.

Bucket, quick, who had it last?

Yes "K" interesting timing for the release of that article, especially when you consider the recent media; CASA propaganda blurb (Skidmore ten commandments); and miniscule SOEs based on Forsyth review recommendation on 'Just Culture' principles:
 

From off the Embuggerance thread - 'Just Culture' & incident reporting probity?- Part II 

Aviation safety vs the “prosecutorial imperative”. Indiscriminate prosecutions erode safety culture




...The great thing about the just culture approach is not merely that it produces timely information that can save lives, but that the information is widely shared among those who can benefit from it. There are searchable online databases containing massive amounts of vitally important safety-related information. With today’s sophisticated analysis and artificial intelligence, it is possible to predict incipient dangerous conditions and remedy them well in advance of an actual system failure.

An Emerging Consensus: deficiencies are best addressed by a "just culture" approach

The value of just culture has been widely acknowledged by regulatory authorities. The FAA last June issued a new “compliance philosophy” (FAA Order 8000.373, June 26, 2015) that places new emphasis on non-punitive means of rectifying deviations from regulatory requirements when disclosed. Noting that some deviations arise from factors like flawed procedures, simple mistakes, lack of understanding, or diminished skills, the FAA believes that such deficiencies “can most effectively be corrected through root cause analysis and training, education or other appropriate improvements to procedures or training programs for regulated entities....” In other words, not through the imposition of penalties. The objective, quite clearly, is to encourage more voluntary reporting in the interest of ensuring that the safety management systems required of all airlines are working optimally.

“CASA embraces, and encourages the development throughout the aviation community of, a ‘just culture,’ in which people are not punished for actions, omissions, or decisions taken by them that are commensurate with their experience, qualifications and training.”

Just last month Australia’s Civil Aviation Safety Authority issued a new statement of regulatory philosophy that even more explicitly embraced the just culture approach. The agency wrote:

“CASA embraces, and encourages the development throughout the aviation community of, a ‘just culture,’ in which people are not punished for actions, omissions, or decisions taken by them that are commensurate with their experience, qualifications and training.” 

Earlier this month, the European Commission convened a meeting in Brussels to introduce a “European Corporate Just Culture Declaration.” The Declaration said: “It is acknowledged that, in an operational aviation industry environment, individuals, despite their training, expertise, experience, abilities and good will, may be faced with situations where the limits of human performance combined with unwanted and unpredictable systemic influences may lead to an undesirable outcome.”

There’s a bumper sticker that makes the same point in fewer words. It can be paraphrased as “Stuff happens.”

The declaration then continues: “Analysis of reported occurrences by organisations should focus on system performance and contributing factors first and not on apportioning blame and/or focus on individual responsibilities....”

Very clearly, there is an emerging consensus -- among regulatory agencies and the industry -- that encouraging voluntary disclosure of safety information is in everyone’s interest, and that the best way to do so is to apply non-punitive remedies to deficiencies that are voluntarily disclosed.

ICAO and Protection at the Global Level

we have seen too many cases in recent years in which judges, prosecutors, and plaintiffs’ attorneys have sought access to this vitally important safety information.

Despite this consensus, however, we have seen too many cases in recent years in which judges, prosecutors, and plaintiffs’ attorneys have sought access to this vitally important safety information. In a growing number of instances, they have succeeded. If that trend were to continue, you can be assured that the essential flow of safety information would simply dry up.

This danger is increasingly understood and it’s now an issue that’s being tackled globally, most importantly at ICAO.

Five years ago, an ICAO High-level Safety Conference recommended the development of new guidance – what ICAO calls “Standards and Recommended Practices” or “SARPs” – to be included in a new annex to the Chicago Convention devoted to safety management. The annexes to the Convention, as you probably know, are where the high-level principles enunciated in the treaty are turned into more specific and granular guidance.

They aren’t self- executing; they have to be implemented through national laws and regulations in order to be effective, but that’s generally what happens. It happens because the quality of a government’s aviation safety oversight is measured by the extent to which it has implemented ICAO’s SARPs and other guidance.

The new SARPs envisioned five years ago were to spell out government responsibilities for the protection of safety information. The protection of information derived from accident investigations was already addressed to some extent in the accident investigation annex -- Annex 13. The new SARPs were intended to reinforce those protections and explicitly cover information reported via the safety management systems that are now a mandatory ingredient in airline operations – including, of course, the voluntary reporting I’ve been talking about. This new guidance will be included in the new safety management annex -- Annex 19. And lest there be any doubt, the protection contemplated is protection from prosecutors, judges, and yes, even trial lawyers.

Some of the most important provisions can be found listed under new “Principles of protection” proposed for Annex 19. The first principle is that “States shall ensure that safety data or safety information is not used for: a) disciplinary, civil, administrative and criminal proceedings against employees operational personnel or organizations; b) disclosure to the public; or c) any purposes other than maintaining or improving safety; unless a principle of exception applies.”


The “principles of exception” are what you would expect – cases in which the conduct in question clearly crosses the line from an honest mistake into the area of reckless endangerment, gross negligence, willful misconduct, or whatever you want to call it -- conduct that would always be subject to prosecution under applicable national laws.


But the overarching idea, simply put, is that penalizing honest mistakes merely impedes the flow of valuable safety information and thereby actually increases the risk profile of the aviation sector.

ICAO is moving towards a basis for a standard global approach by end-2016

The new provisions were circulated to governments for a final review last July in something ICAO calls a “state letter.” Any further comments from the governments were due a week ago, by October 15. The next step will be a review by ICAO’s Air Navigation Commission with the intention of presenting the language to the ICAO Council – ICAO’s governing body -- for final approval next March. Nobody expects to hear any dissent. The new provisions will then become effective in November of next year.

There is still an open question as to when the new provisions will become applicable to governments – 2018 or 2020 are the options being discussed. As I indicated earlier, nothing in an ICAO annex is self-executing; to be effective and enforceable, the guidance has to be translated into national law by governments. My guess is that a great many governments won’t wait for the new language to become effective but will start their legislative processes working even sooner.

All of this is good news for the airlines, of course, but it is even better news for their customers – including you and me. Aviation is already the safest mode of transportation, and by a wide measure. But air traffic is predicted to double over the course of the next 20 years.

That means that we have an obligation to do all we can to make the remarkable safety management systems we rely upon today even better. The changes in law that I’ve discussed will be an essential element in that improvement. 

miniscule SOE:

..8. work closely with the ATSB to ensure continued arrangements are in place, consistent with the current Safety Information Policy Statement and informed by ‘just culture’ principles, for the appropriate sharing and use of safety information by CASA and the ATSB;

Forsyth recommendation:

..17. The Civil Aviation Safety Authority publishes and demonstrates the philosophy of ‘just culture’ whereby individuals involved in a reportable event are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training. However, actions of gross negligence, wilful violations and destructive acts should not be tolerated..

So is the FSA article a rather vain attempt by the CASA white hats to get a very real message out or just another - Oliver endorsed -  attempted spin'n'bulldust, rhetorical flourish to display artificial compliance/progress with actioning the Forsyth recommendations??

Either way the chances of a sound 'just culture' SSP (ICAO Annex 19) being successful in Australia is nugatory, while Oliver refuses to address the toxic culture of distrust that the industry continues to have with the regulator.

The heading & last paragraph of the FSA article IMO perfectly highlights the major roadblock that needs to be broached before there can be any effective reform of CASA & their massive current & proposed volumes of industry killing regulations: 

Blame, shame and safety


Each facet of bullying and public shaming has a direct impact on safety. From the ‘I would have done it differently’ culture that emerges after every accident, to the shaming of pilots who have near misses, the shame game turns often-trivial accidents into potential fatals. Do I need to spell out how?

Every time a person shames another, they’re implicitly declaring, ‘I would never be that stupid, careless or heavy handed’. How can you be so sure? Do you know and understand the factors and pressures that faced the pilot who had the incident? Can you, hand-on-heart, say you have always resisted them?

Every accident and incident in aviation provides an opportunity to learn a lesson. Blaming and shaming detracts from that opportunity. By criticising others rather than re-examining one’s own attitudes and practices, blame becomes a lesson wasted. If the industry is to promote a culture of safety and transparency, the blame game cannot go on.

     
Oliver you're despicable...

MTF....P2