[Peetwo]

'Just culture' & incident reporting probity?

The above post title you might think would be much more appropriate on an ATSB thread?? However given the overwhelming evidence from recent Senate Inquiries, many of the ASRR submissions and evidence given to the Forsyth panel, one can only conclude that this is very much a CASA issue. This is also clearly evident in recommendation 17 of the Forsyth report & in the Miniscule's SOE: 

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.    

 

CASA 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;


ATSB SOE: ...Work closely with CASA 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 the ATSB and CASA;

Here is a link for -  Safety information policy statement

From this policy statement it is stated:

This policy is consistent with contemporary practice in leading aviation States.  It is also in line with the new ICAO Annex 19 – Safety Management.  Standard 5.1.1 of the Annex requires that:


Each State shall establish a mandatory incident reporting system to facilitate collection of information on actual or potential safety deficiencies.

Recommended practice 5.3.1 states:

State authorities responsible for the implementation of the State Safety Program should have access to appropriate information available in the incident reporting systems.

  
However from the footnote it would seem to indicate that there has been no updates to this policy since 2012-13:

* In 2012, the ATSB sought comments on proposed regulatory changes covering mandatory reporting of accidents and incidents and confidential reporting of safety concerns in Australia. CASA sought comments on proposed new Part 119 of the Civil Aviation Safety Regulations dealing with the certification and management of Air Transport Operators.

This was despite the findings & recommendations of the Senate AAI (Pel-Air), TSBC & Forsyth review reports..

Although OST (Skidmore) would seem to have taken note of the Government's support of the Forsyth R17 (ref OzFlying) & the DPM SOE...

 "In the coming months, I will be leading CASA in the implementation of a just culture approach to aviation safety regulation in Australia. We will work to develop a regulatory and an operational environment where genuinely honest mistakes are recognised for what they are—opportunities for learning and improvement.


"CASA’s response will be to understand why the mistakes were made and how the likelihood that the same mistakes will occur in the future can be reduced. Where the people and organisations involved demonstrate a willingness and ability to address errors and omissions in a responsible and constructive way, CASA will not need to take enforcement action. Certainly no punitive action will be necessary.


"We will encourage the individuals and organisations involved to identify and understand the factors behind mistakes."


However, the new approach doesn't mean that NO action will be taken, with Skidmore pointing out that some action will need to be necessary in the interests of safety.

According to Skidmore, the advantage of a just culture approach is more opportunity for everyone to learn.


"The advantage of a just culture approach is that it encourages people to be open and accountable about their mistakes, so there is a better reporting of errors and the ability to learn from them is enhanced.


"Fear of punishment doesn’t stop people from making mistakes. But mistakes can be avoided by robust safety systems, training and an overarching commitment by everyone to achieving the best possible safety outcomes."

   
We all know from recent evidence that this is merely rhetoric (spin and bulldust ) and until someone has the balls to undertake a top to bottom purge of the perfidious, sociopathic subculture of individuals within, we will continue to get miscarriage of power (embuggerance) to circumvent government policy.

Potential embuggerance example:

 Point of difference - CAR 301 notices to the ATSB?

I know it is early days yet but the ridiculous, flippant comment from CASA (in the above article) would seem to indicate that Fort Fumble is not remotely interested in this incident.

Turning back time some 20 months to another incident occurring during the take off sequence, at Kununurra Airport WA, 22 January 2013 - AO-2013-023:  

On 22 January 2013, the pilot of a Cessna 182R aircraft registered VH-OWZ (OWZ), took off from Kununurra Airport, Western Australia on a charter flight with one passenger. When at about 100 ft above ground level, with insufficient runway distance remaining to abort the takeoff, the pilot retracted the landing gear. Immediately after, the engine failed.


Due to the low altitude, the pilot confirmed that the engine controls were in the full forward position and that the fuel tank selector was on ‘both’. The pilot then looked for a suitable place to land and saw a suitable field to the north.

After extending the landing gear and selecting full flap, the main landing gear touched down in long grass and the aircraft decelerated rapidly. When the nose gear touched down, it dug into boggy ground and the aircraft flipped over, coming to rest inverted. The pilot and passenger received minor injuries and the aircraft sustained substantial damage.

An examination of the aircraft was carried out by an independent Licensed Aircraft Maintenance Engineer (LAME). No contaminants, including water, were found in the fuel or filters. An engine tear down was not performed and the reason for the engine failure could not be determined.

As a result of this occurrence, the aircraft operator has advised the ATSB that they are taking the following safety actions:

• Fuel contamination procedures: They will create a log for all company aircraft that will contain details of any water contamination found in fuel drains. In addition, after heavy rain is experienced, all aircraft fuel tanks will be tested for water contamination.
  
• Emergency response equipment: Equipping a vehicle with an ‘accident kit’, which includes fire extinguishers, a fire suit, and first aid kit for use in an on-airport emergency.
  
  

This accident highlights the benefits of conducting a self-briefing before takeoff and ensuring that emergency procedures, particularly those related to critical phases of flight, are clear and familiar. This assists pilots with responding to an abnormal or emergency situation promptly and ensuring the best possible outcome can be achieved. Generally speaking, if you self-brief your plan of action just before flight, you have more chance of ‘staying ahead’ of the aircraft and being able to concentrate on flying.
 
Aviation Short Investigation Bulletin - Issue 18

Okay all good, we end up with yet another wishy-washy desktop investigation & short investigation bulletin report from the ATSB...

However what perked my interest with this incident, was the apparent disassociation with the ATSB/LAME findings & safety message and the apparently unprompted safety actions by the operator:

Aircraft operator

As a result of this occurrence, the aircraft operator has advised the ATSB that they are taking the following safety actions:

• Fuel contamination procedures: They will create a log for all company aircraft that will contain details of any water contamination found in fuel drains. In addition, after heavy rain is experienced, all aircraft fuel tanks will be tested for water contamination.

• Emergency response equipment: Equipping a vehicle with an ‘accident kit’, which includes fire extinguishers, a fire suit, and first aid kit for use in an on-airport emergency.

Hmm..passing strange? To me those actions smack of other external influences (i.e. the micro-managing big "R" regulator).

And then I happened upon a recent ATSB FOI request release: FOI 14-15(12) - Disclosure Log Documents_Redacted

Q/ First question is why would anyone want to request this information?

Q/ Why would CASA be even remotely interested in this incident?

Q/ From the ATSB responses to the CASA CAR 301 'demand', it would appear that it is an accepted SOP for CASA to issue such a demand. So is this normal procedure for CASA? It seems very OTT and also seems to be impinging on the independence of the ATSB and in direct conflict with certain principles as outlined in the TSI Act?

Anyway that's my Sundy OBS & QON - Gobbles..anyone

    
Finally I would like to draw attention to the following statement from Nick Xenophon in his additional comments - Who guards the guards themselves? - to the Senate AAI report:

1.23      It is my view that CASA, under Mr McCormick, has become a regulatory bully that appears to take any action available to ensure its own shortcomings are not made public. This poses great risks to aviation safety, and the safety of the travelling public. Equally, the ATSB—which should fearlessly expose any shortcomings on the part of CASA and other organisations to improve aviation safety—has become institutionally timid and appears to lack the strength to perform its role adequately. Both agencies require a complete overhaul, and I believe it is only luck that their ineptness has not resulted in further deaths so far. There is an urgent need for an Inspector-General of Aviation Safety, entirely independent of the Minister and his department, to be a watchdog for these agencies.

1.24      In the end, this report raises many questions. But if we wish to bring about change and improve aviation safety, we will clearly need to look beyond our inept regulators and ask: who will guard the guards themselves?

 
Take out the names, change the date to today's date and ask would the NX comments & Q ( who will guard the guards themselves?) be any less relevant today? Has anything changed? - I think not...
TICK...TOCK Miniscule; and Malcolm you now own this...P2