Closing the safety loop - Coroners, ATSB & CASA

A closed safety loop - found one!  Wink

Caught this via the NT News:

Quote:[Image: 2ae2462476247d616361309cf4c359c6?width=1024]

Chopper crash could have been multiple fatality if not for fuel tank standards changes

January 20, 2018 1:00am

THE helicopter crash in Central Australia which left two men with spinal injuries this week could have been a multiple fatality if not for changes to fuel tank standards sparked by a series of earlier deadly crashes.

The design of the Robinson R44 model helicopter involved in the crash was changed after three similar crashes in NSW resulted the deaths of eight people between 2011 and 2013.

In the most recent incident, which bears eerie similarities to Wednesday night’s crash, the pilot and three passengers were killed when the chopper they were in rolled onto its side after striking trees.

The deaths were attributed to a fire which started when the helicopter’s aluminium fuel tank leaked “following an otherwise survivable impact”.

That incident led to action from the Civil Aviation Safety Authority, which now requires a bladder-type fuel tank to be fitted in all R44s in Australia as well as other fuel system improvements.

There are 52 R44s registered as operating in the Northern Territory and Wednesday’s crash is the third in the NT since 2016 involving an R44 or its two-seater counterpart, the R22.

None of those crashes have been fatal and no injuries were reported in the two previous incidents.

An Australian Transport Safety Bureau spokesman said it was too early in the investigation to say conclusively whether the fuel tank change prevented the deaths of all those on board on Wednesday.

“However, it is expected that the mandated change to bladder-style fuel tanks for all R44 helicopters in Australia would have reduced the risk of a post-impact fire in this occurrence,” he said.

The 46-year-old woman injured in Wednesday’s crash was flown to the Royal Adelaide Hospital on Friday in a serious but stable condition.

The 32-year-old pilot and his 32-year-old passenger already in hospital in Adelaide were in a stable and serious condition respectively. The other passenger, a 35-year-old man, suffered minor injuries.

 I am sorry to burst the 'NT News' scoop bubble but if they'd bothered to dig a little deeper they may have discovered that the identified safety issue predated those (2011-2013) NSW reoccurrences for the better part of 15 years (now 2 decades). And if it wasn't for the lobbying of certain fatal victims NOK (like the Cousins in WA) and the efforts of a certain Senate Committee, we may have been witness to another fiery fatal Robbo accident... Angel

Reference: Sunday Ramble - Beyond the pale 

Quote:..Some on here will remember that at Budget Estimates in May 2013 (i.e. 2 months after the tragic Bulli tops accident), the matter of the R44 post impact fire accidents were the subject of Senate questioning. Here is a copy of a post of mine off the UP from that time:

Quote: Wrote:Yep the list is growing and the stench is rising!


You can add the Cousin's to that list...remember this from sub16:

Quote: Wrote:“We have been to Martin Dolan Chief Commissioner ATSB, Albanese, John McCormick, Local Member John Castrilli - who did write a letter to CASA on our behalf but that was it! John McCormick insulted us in his response stating that "CASA is unaware of any other accidents involving this company’s aircraft". Oh My God how insulting to our intelligence. So in their eyes Kenny's Mob have never been involved in other incident!

How many fatalities does a Company need to have to be anything recorded as an ACCIDENT! At the inquest the CEO of Heliworks was questioned about his Statutory Declaration and had he completed - he disclosed he did not complete it and the Company had told him what to write! How could that be admissable in a court of law?

They were aware that this cowboy operation existed out at the Bungles but once again NO ONE would do a thing to stop them...............

It took 2 yrs 7 mths after the accident for the inquest to be held and we did not get the final report until a further 6 months!! Over 3 years!!”


“Well we had our inquest which was an absolute joke and embarrassment for the fact that so many documents were not produced / lost / created etc and no one did a thing about it. Our Coroner Ms Fricker left a lot to be desired and the fact that in the 2 years 7 months not one person in the court room excluding us had even visited the accident site or gone out to witness just what happens out there. We came away just blown away with the fact that so many things were dismissed/ allowed/undisclosed and were allowed to be.

That smell of money I think well and truly came into play!!!
I personally lost all respect for our government representatives, law, safety authorities after sitting in that court room for 5 days and listened to excuses on their behalf...instead of reasons to rectify and was horrified after the evidence given that it was declared and accident.

As I said in court this was an Accident waiting to happen and will occur again!!The coroner in her report even noted the number of helicopter accidents just since the inquest - approx 4 month....and not one recommendation was handed down. She used the words like Breached and Failed to comply in her report and yet not one

Carolyn Cousins. (mother of Jessica Cousins) Slingair Robinson 44 Bungle Bungles 14

September 2008 4 fatalities

Although according to Beaker this accident was a high-energy impact:

Quote: Wrote:Mr Dolan: There had been a number of post-crash fires associated with R44 helicopters. In the vast majority of those cases they represented high-energy impacts, which is to say accidents that were unlikely to have been survivable and which would have led to a post-crash fire in almost any helicopter.

Senator XENOPHON: So you are saying that the retrofitting would not have made any difference?

Mr Dolan: That would be our general assessment.

Senator XENOPHON: Take it on notice, because I have a few other matters to raise. You are saying that, from a causation point of view, even retrofitting the helicopters with that protective bladder, it still would have been a fatal accident?

Mr Dolan: On the facts that were available to us. We are not aware of any previous to Cessnock. I do not think we are aware of any of the low-energy collisions leading to that sort of thing. There were, as you say, a number of high-energy collisions that would have led to a ruptured fuel tank in any helicopter and therefore a great likelihood of a post-crash fire. Those are the sorts of accidents that generally are not survivable.

But on the evidence in the bureau report it would appear that there was a strong possibility the pilot at least survived the crash impact only to be overcome by the post impact fire, from the report:

Medical and pathological information
The post-mortem examinations for all occupants of the helicopter described varying degrees of injuries consistent with the high vertical velocity impact. All sustained extensive thermal injury.

The pilot’s post-mortem report indicated that he was found ‘...a slight distance from the damaged aircraft.’

You will notice that the post-mortem didn't appear to explore how the victims died i.e. did they succumb to their impact injuries or the 'extensive thermal injuries'. Nor was IMO the post-survivability issues properly explored by the ATSB. It was almost as if the ATSB accept that if a chopper comes (in particular a Robbo) down hard it will inevitably burn!

Yes 004 it will be interesting to watch and I bet there will be a couple of interested Senators tuned in as well..given the QONs outstanding on the subject of post-impact fires and R44s

Here's the links for the high energy post-impact fire fatalities to which Senator X refers:

And here is a link for the report from the Jaspers Brush tragedy - AO-2012-021 - that included these two safety issues:

Quote: Wrote:Fitment of rubber, bladder-type fuel tanks to R44 helicopters

And in ICAO Annex 13 Ch 6 under Safety  Recommendations  it is stated...

"..6.8 At any stage of the investigation of an accident or incident, the accident or incident investigation authority of the State conducting the investigation shall recommend to the appropriate authorities, including those in other States, any preventive action that it considers necessary to be taken promptly to enhance aviation safety.

6.9 A State conducting investigations of accidents or incidents shall address, when appropriate, any safety recommendations arising out of its investigations to the accident investigation authorities of other State(s) concerned and, when ICAO documents are involved, to ICAO..."

So what is the ATSB excuse for sitting on these SRs until now (over two years after the fact)?? No this is just another cynical attempt to gain credibility where none is due..
FFS get rid of the Muppet.   [Image: angry.gif] 
Errr (grumble..grumble - Angry ) - no comment! Dodgy

MTF...P2 Cool

Real World vs The wizards of Oz aviation safety obfuscation Dodgy  

References from AP forum this week:


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

Quote: Wrote:»» 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 (above). Anyone else get the impression there was no love lost between the former DAS McComic and BC [Image: huh.gif]

The theme for this week's SBG revolved around the Yin and Yang - or reality vs fantasy; black hats vs white hats - of the Australian aviation safety bureaucracy. This gives me the perfect opportunity to draw attention some excellent articles, tackling the closing of safety loops, from the real world of aviation safety; rather than the self-serving, 'BOLLOCKS' bureaucratic world of aviation safety administration in Sleepy Hollow, Can'tberra:

Quote:[Image: crisis.gif]

Irony is wasted on the stupid" | : Home of PAIN :
So first from AIN magazine:
Quote:AINsight: Rogue Pilots or Just Bad Procedures?
by Stuart “Kipp” Lau[/url]
 - June 22, 2018, 8:55 AM

Procedural noncompliance is a topic that gets a lot of attention. In most recent studies, much of the focus centers on pilots who intentionally deviate from a procedure because they are either too complacent, unprofessional, or worse, just bad apples.

The “fast thinker”—those seeking cognitive ease—might buy into this notion. For them, blaming an incident or accident on a “rogue” pilot is easy. Pilots should just follow the procedures and incidents and accidents won’t occur.

Their solution: remove that individual, issue a bulletin for the rest to “comply,” and the problem will go away, right?

The “slow thinker”—those wrestling with cognitive strain—will question the notion of a “rogue” pilot, understanding that complex issues don’t have one single solution, nor will they simply go away. The solution in this case might begin with identifying the human-factors issues associated with noncompliance and a healthy reflection on the procedures themselves. Line operations safety assessments (LOSA) studies suggest a high prevalence of noncompliance often points to an ineffective or bad procedure.  

At one time, procedural noncompliance was on the NTSB’s “Most Wanted List” and currently is a top safety issue for the NBAA Safety Committee. NBAA identifies procedural noncompliance as a significant contributing factor in aircraft accidents and incidents.

Furthermore, NBAA recommends, “Aviation professionals in all vocational categories must become aware of the extent that noncompliance has proliferated in business aviation, identify the causal factors for noncompliance and develop workable solutions that eliminate these events.”

Universally, it’s recognized that good procedures ensure standard pilot actions. Likewise, pilots adhering to good procedures enhance aviation safety. Thus, there’s typically a bad outcome when pilots intentionally don’t follow procedures. In fact, it’s a very slippery downward slope.

The LOSA Collaborative, founded by Dr. James Klinect, has more than 20,000 observations in its archive. This data shows that, on average, “Flights that have two or more intentional noncompliance errors have two to three times as many mismanaged threats, errors, and undesired aircraft states as compared to flights with zero intentional noncompliance errors.”

Intentional noncompliance by pilots might be more closely related to science than bad behavior. Some human-factors studies suggest that there are a number of issues related to a pilot becoming intentionally noncompliant. Often, these pilots, given a poorly written procedure, simply do not agree with the procedure and might believe their way is better—“an informed workaround.” Others might not fully understand a procedure or the risk associated with not complying. Additional factors such as fatigue can also play a role in intentional noncompliance.

Researchers also point toward three “perceived justifications” of being noncompliant: rewarding the violator (for example, “I get home earlier if I don’t go-around”); knowledge of associated risk (for example, “My risks are justified because I know better…”); or consideration of peer reaction (for example, “My reputation precedes me. I am a good pilot.”). The trick is to break these perceptions.

Organizations also have some culpability when it comes to procedural noncompliance. Operators must understand that there are indeed bad procedures. When it comes to developing and writing good procedures, words and actions matter.

Advisory Circular 120-71B provides some outstanding guidance on the design, development, and implementation of SOPs and checklists. It goes into great detail about the importance of providing flight crews background information on a new procedure or a change in existing procedure. Background helps a crew “buy into” the procedure by providing context and relevance.

According to the AC, implementation of any procedure is most effective when the procedure is appropriate for the situation; the procedure is practical to use; crewmembers understand the reasons for the procedure; pilot flying and pilot monitoring duties are clearly defined; effective training is conducted; adherence to standard is emphasized; and crewmembers understand the risk and hazards of not following the procedures.

For any developer or manual writer, this AC is a must. As an example, the use of ambiguous words—such as should or may—often leads a crew to noncompliance, by simply giving them an option not to comply.

The AC recommends the use of more positive words—such as do and must—since they are easier to read and less likely to be misunderstood.

Procedural noncompliance is a difficult issue to identify within an organization. LOSAs, when compared to the other voluntary safety programs, are one of the most effective tools to identify procedural noncompliance by highlighting areas where it is most prevalent. From those results, an organization can determine if it’s a pilot problem or organizational problem

Pilot, safety expert, consultant, and aviation journalist Stuart “Kipp” Lau writes about flight safety and airmanship for AIN. He can be reached via email.

Next from World renown Flight Instructor John (& Martha) King, where even Dick gets a mention... Wink :


[Image: Safety_Cessna_Airbus_FB_640px.jpg]

Article appeared in Flying Magazine January 2018 by John King

“There can be no compromise with safety.” “Safety is our number one priority.” You hear these kinds of quotes all the time from well-meaning people—very often people like the Secretary of Transportation or the Administrator of the FAA. The assertions are meant to be comforting, and they are—especially after a crash. They assure the public of the firm resolve by people in power to do better. The problem is they aren’t, and can’t be, true.

You can’t start an engine without compromising safety. If safety were our number one priority, we’d never move an airplane. Clearly going somewhere is in itself a demonstration that moving the airplane ranks ahead of safety. It would always be safer to stay put. These little intellectual dishonesties tend to end discussion and substitute for genuine analysis on the subject.

It can be discomforting to talk openly and honestly about safety. So we often make false assurances and otherwise deceive ourselves. For instance, we usually talk about safety as if it were an absolute. But absolute safety is an impossibility. In reality, safety is relative. Every activity has a greater or lesser degree of risk associated with it. Still, when someone departs on a trip, we usually say, “Have a safe trip” as a polite expression of goodwill. We say this when we know having a genuinely safe trip is literally impossible.

Not only do we find it uncomfortable to admit to ourselves that we can never achieve absolute safety, but we sometimes utterly lie to ourselves in order to not have to face reality about safety. General aviation pilots used to frequently tell themselves, and their passengers, that the drive to the airport was the most dangerous part of the trip. They wanted to believe that flying their piston-engine general aviation airplane was safer than driving. When it became known that the fatality rate per mile in a general aviation airplane was seven times that of driving, they had a very hard time accepting that reality. (On the other hand, for various reasons travel on the airlines is in fact seven times safer than travel on the roads.)

Sometimes our self-deception on the subject of safety just reflects wishful thinking. After a series of commuter airline crashes, the Administrator of the FAA attempted to mandate one level of safety for little airplanes as well as big airplanes. The problem is that it is not possible for a small airplane to be as safe as a Boeing 747. Safety equipment is adds weight. A little airplane can’t carry the weight of the safety provisions of a 747. Plus, safety is expensive. A little airplane can’t afford the cost of safety equipment the way a bigger plane can. But who wants to tell that to someone about to fly in a smaller airplane?

On the other hand, when noted Australian thought-leader and avid pilot (weight-shift trikes, single-engine airplanes, helicopters, and jets) Dick Smith was Chairman of the Australian Civil Aviation Safety Authority, he steered people away from disingenuous talk about safety. He shocked people by talking about “affordable safety.” His point was that when safety becomes too expensive there can be a net reduction in safety. When excessively expensive safety measures are mandated, the cost of flying goes up. At some point people take less-safe surface transportation instead, and fatalities go up.

Another problem with the way we talk about safety has to do with how safety advice is normally given. It often provides very inadequate guidance. Safety advice usually takes a negative approach, stating what you cannot do rather than focusing on positive things you should do. In many cases it is limited to a hodgepodge of rules and sayings. The rules and sayings may all be good, but they are not adequate, because they fail to provide the big picture and structure.

Moreover, safety advice can even generate resistance. It can be preachy—taking on an off-putting air of smugness and superiority. It is not uncommon for advisors to suggest that someone does not exercise proper “judgment” or “aeronautical decision-making.” This comes across as a vague, demeaning criticism, but once again, with very little guidance.

So what is the alternative?

We need to change our vocabulary. In nearly every case, it is more insightful and helpful to talk about risk management. The concept of risk management suggests a proactive habit of identifying risks, assessing them, and exploring mitigation strategies for them. Those words “risk management” provide much-needed guidance about what people should do to get a safer outcome, in a way that the condescending criticisms, and emphasis on “safety,” do not.

One of the problems about the way we sometimes use the word “safety” is that if someone wants something done a certain way, they can often just simply trot out the word “safety,” or for that matter, “security,” and get carte blanche with little analysis. But the words “risk management” require a more thoughtful discussion—including in most cases identification and assessment of the risks and the appropriateness of the mitigation strategies.

When an aviation tragedy occurs, rather than trying to reassure and comfort people by promising things that are not possible, aviation leaders should say, “Our job is to understand the risk management failures that allowed this to happen and see that they do not occur again.”

Much to their credit, the FAA’s Flight Standards Service has embraced “risked-based decision-making” as one of its core values. The idea is that in this business of creating rules about how aviation should be run, they will now think in terms of the risks of an activity. Every safety measure has a trade-off in loss of fun and utility. When risked-based decision-making is a core value, that trade-off will be taken into consideration during rule-making.

The good news is that much of the aviation community is now focused on “risk management” rather than “safety.” First, flight schools are moving towards scenario-based training in order to help pilots learn risk management. The idea is to give a learning pilot the tools to habitually identify, assess, and mitigate risk. Then when that pilot is evaluated during the practical test, the FAA’s new Airman Certification Standards (ACS) require their risk management to be evaluated in every area of operation.

Martha and I have been promoting straight talk about safety for years. We finally figured we must be making progress when an attendee came up to us after a talk and said, “Have a relatively safe trip home.”[/size][/color]

 JK - Choccy frog is in the mail... Wink 

MTF...P2  Tongue

For the record? 

As we all now know the ATSB in the course of the 1st PelAir cover-up investigation bizarrely decided, seemingly in contradiction to nearly all the principles of ICAO Annex 13, to not retrieve the CVR/FDR recorders from the wreck of VH-NGA (see above).

One of the lame arguments for not retrieving the boxes was that the CVR would only have covered the last 2 hrs of flight crew comms and radio calls, therefore would have been of limited value. What was never really touched on, was the over 100hrs of hugely invaluable data that was captured on the FDR. This data if properly analysed could have given an insight into such things as whether other aircrew operated VH-NGA in accordance/compliance with company SOPs and the CASA AOM. 

The following is an excellent NTSB blog that highlights how recorded flight data information can be instrumental in identifying and mitigating internal operator safety risk issues:

By John DeLisi, Director, Office of Aviation Safety
On November 10, 2015, a Hawker 700A operating as a Part 135charter flight crashed on approach to Akron Fulton International Airport in Akron, Ohio. The crash killed 9 people. During our investigation, we learned that the first officer was flying the airplane, although it was company practice for the captain to fly charter flights. We also discovered that the crew did not complete the approach briefing or make the many callouts required during approach. Additionally, the flight crew did not configure the airplane properly, the approach was unstabilized, and the flight descended below the minimum descent altitude without the runway in sight.

[Image: akron-ohio.jpg?w=474]
NTSB investigators at the scene of the crash of a Hawker 125-700 into an apartment building in Akron, Ohio

How could this happen? Wasn’t the flight crew trained to follow standard operating procedures (SOPs)? (Yes, they were.) Didn’t they know when to lower the flaps? (Yes, they did.) Yet, weren’t they flying the airplane contrary to the way they were trained? (Yes, they were.)

The crew ignored, forgot, or improvised their company’s SOPs and the airplane’s flight manual information. Even more disconcerting was that, upon our review of the cockpit voice recorder (CVR), it appeared that this type of haphazard approach was fairly routine for them. How could that be?

The NTSB investigators discovered that no one at the company was monitoring—or had ever monitored—the way this crew flew the airplane. Because the airplane was not equipped with a flight data recorder, a quick access recorder, or any type of data monitoring device, the operator had no insight into what was happening inside the cockpit or how this crew was flying its airplane. The fact was that this crew was able to fly an airplane carrying passengers in an unsafe, noncompliant manner, which ultimately led to tragic consequences. If the operator had better insight into the behavior of its flight crew and had taken the appropriate actions, this accident may have been prevented.

That is a lesson learned the hard way—and we have seen similar such situations in several accidents the NTSB has investigated in recent years.
It’s time to be proactive about aviation safety and accident prevention! The NTSB believes flight data monitoring (FDM) programs for Part 135 operators—which includes charter flights, air tours, air ambulance flights, and cargo flights—is one answer to this problem.

An FDM program can help an operator identify issues with pilot performance, such as noncompliance with SOPs, and can lead to mitigations that will prevent future accidents. Too many Part 135 operations occur in which the operator has no means to determine if the flight was being flown safely. An FDM program can help companies identify deficiencies early on and address patterns of nonstandard crew performance. Most importantly, with an FDM program, pilots will know that their performance is being monitored. As a result of the Akron investigation, the NTSB recommended that the Federal Aviation Administration (FAA) require all Part 135 operators to install flight data recording devices. But it’s not enough to just capture the data; we also recommend that operators establish an FDM program to use the data to correct unsafe practices. The FAA has yet to act.

But some Part 135 flight operators aren’t waiting for FAA mandates; they have already made the investment in such a proactive safety program—and with great success. One operator I read about started an FDM program recently and is having success using the data in a nonpunitive fashion to monitor approaches. With this critical data at its fingertips, the operator is attempting to identify instances of incorrect aircraft configuration or exceedances of stabilized approach parameters. Designated line pilots assess the data captured in the FDM program to determine if further follow up is needed.

Another Part 135 operator involved in an accident near Togiak, Alaska, investigated by the NTSB recently made the commitment to equip every airplane in its fleet with a flight data recorder. The operator told us the data will “further enable [the company] to review compliance with company procedures through data analysis, similar to a Part 121 operation.”

[Image: togniak-ak.jpg?w=474]
NTSB Member Earl F. Weener (center), Director of the Office of Aviation Safety, John DeLisi (right) and Loren Groff (left), Senior Research Analyst in the NTSB’s Office of Research and Engineering served as the board of inquiry for an investigative hearing held in Anchorage as part of the ongoing investigation of the crash of flight 3153 near Togiak, Alaska

Kudos to both these operators for learning from past lessons and committing to a culture of safety.

Last year, a Learjet that was being repositioned following a charter flight crashed on approach to an airport in Teterboro, New Jersey. Both crewmembers died. While the final NTSB report on this accident has not yet been released, our analysis of the CVR revealed that the first officer, who was not permitted by the company to fly the airplane, was, in fact, flying the airplane. During this flight, the captain was attempting to coach the first officer.

The first officer flew a circling approach; however, when the airplane was one mile from the runway, the circling maneuver had not yet begun. The first officer gave the controls to the captain, who proceeded to bank the airplane so steeply that the tower controller said the wings were “almost perpendicular to the ground” just prior to impact.

It comes as no surprise that the performance of this flight crew was not being monitored by any FDM program.

Isn’t it time to make passenger-flying operations safer? We see this type of program on major commercial Part 121 airlines, so why not on Part 135 aircraft? After all, flight data monitoring is the best way to ensure pilots are flying safely and passengers reach their destinations.

MTF...P2  Cool

Aviation safety FAA style: 'Round up the usual suspects' -  Wink

While on the world's most successful and statistically safest aviation system, the following is an excellent FAA flight safety initiative using the '50s movie classic Casablanca to help deliver the safety messages... Wink    

Quote:"Round Up the Usual Suspects"
Corralling the Common Causes of GA Mishaps

by Susan Parson, FAA Safety Briefing

The mission of this publication is to be the FAA safety policy voice for non-commercial GA. We also aim to improve GA safety by making airmen aware of FAA resources, helping readers understand safety and regulatory issues, and encouraging continued training.

All those aims come together especially well in this issue of FAA Safety Briefing, which takes an admittedly whimsical and, we hope, engaging Casablanca-themed approach to addressing a deadly serious issue: the persistently consistent causes of GA safety mishaps.

[Image: dc0f24d0-40ac-4c64-92b6-161616f0c0c0.jpg...&size=1024]
Meet the Prime Suspects

The collection of common causes for GA accidents and incidents is remarkably (maybe depressingly) consistent. The AOPA Air Safety Institute’s most recent Joseph T. Nall Report notes that a whopping 75 percent of causes of non-commercial fixed-wing accidents can be attributed to the action — or inaction — of the pilot.

The mix of specific pilot problems shifts; just for example, the Nall Report notes that reductions in the number of takeoff/climb and adverse weather encounters were offset by increases in numbers attributed to low-altitude maneuvering, descent/approach, and (sigh) fuel mismanagement.

It is also troubling to note that instructional flights are again the second largest category for accidents involving personal flying. While the classic VFR-into-IMC scenario accounted for fewer than five percent of all accidents, these mishaps are deadly. Almost 70 percent of accidents in IMC were fatal, compared to 17 percent of those occurring in VMC.

Though not usually fatal, runway incursions are another elusive member of the not-so-exclusive usual suspects club for GA mishaps. FAA statistics ( show an uptick in national runway incursions as compared with 2017.

The numbers were better for non-commercial helicopter accidents (fatal accidents dropped by 30 percent), but low-altitude maneuvering persists as a leading cause.

Sleuthing for Solutions
We’ll take a look at each of these topics in this issue, all presented through the lens of famous phrases from Casablanca. But while we borrow the immortal “round ‘em up” words of Captain Louis Renault, Casablanca’sPrefect of Police, to talk about the causes, it’s important to emphasize that we don’t subscribe to his post-hoc, enforcement-centered methods of keeping order when it comes to airmen who make honest mistakes. Rather, as Flight Standards Executive Director John Duncan reminds us in this issue’s Jumpseat department, the FAA’s compliance philosophy aims at getting a steady flow of safety information we wouldn’t otherwise have. We then work collaboratively with airmen to prevent accidents from occurring in the first place or, if prevention isn’t possible, to keep them from re-occurring.

It’s Time

We know you’ve probably heard of all the usual suspects before, and you may even have more than a passing acquaintance with one or more of these pesky perpetrators. Safety-minded readers are similarly likely to be familiar with some — maybe all — of the suggested preventions and mitigations, so there may be more than a touch of the “can’t happen to me because I would never do that” mentality. However, somebody does keep falling prey to the pesky perps. So since nobody is immune from making honest mistakes and errors, everybody will benefit if anybody who encounters this issue will take the time to get a “safety booster shot” through reading and heeding the proffered preventions.

To encourage that investment of your time, we challenge you to keep a tally of all the Casablanca-inspired words and phrases in this issue — extra credit if you can identify both the source and the scene. Send us your best guess via the links in Forum or through our social media accounts, and we’ll recognize the winner in a future issue.

Quote:Are you ready?
Click the links under the images below to read the features!

Master of My Fate: Maintaining Aircraft Control

Is that My Runway? How to Avoid Wrong Surface Operations

Maybe Not Today ... Avoiding the Perils (and Regrets) of VFR into IMC

Not an Easy Day to Forget: Remembering Fuel Management Before It’s Too Late

Thinking for Two: Managing Instructional Risk

Learn More Susan Parson (, or @avi8rix for Twitter fans) is editor of FAA Safety Briefing. She is an active general aviation pilot and flight instructor.
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This article was originally published in the July/August 2018 issue of FAA Safety Briefing magazine.
FAA Safety Briefing Webpage

MTF...P2  Wink

Lessons of Flight 3407 not forgottenAngel

While on the FAA theme I note the following tweet from Sully Sullenberger today:

Quote:[Image: iBFo9Lyc_bigger.jpg] Sully Sullenberger @Captsully
I join
@3407Families in applauding Congress for passing this bill and leaving critically important pilot standards intact. There's no substitute for real-world pilot experience. @USDOT and @FAANews must continue to support upholding these vital standards. 

Flight 3407 Families Applaud Passage of FAA Bill Upholding Stronger First Officer Experience Requirements

Buffalo, New York - October 3, 2018 - The 'Families of Continental Flight 3407' hailed today's passage of a five-year FAA Reauthorization Bill by the Senate that left intact stronger entry-level experience requirements for regional airline first officers. This safety initiative was the cornerstone provision of landmark aviation safety legislation unanimously enacted by Congress in 2010, and had been the subject of an aggressive and well-financed lobbying campaign by the nation's regional airlines and their lobbying arm that sought to relax its requirements.

"Kudos to Congress for recognizing what Captain Sullenberger and First Officer Skiles have been saying from Day One, that experience matters and these new safety requirements are working as intended," stated John Kausner of Clarence Center, New York, who lost his twenty-four year old daughter Ellyce when Flight 3407 crashed less than a mile from their family home. "We can’t say thank you enough to Senators Schumer and Gillibrand, as well as Senators Nelson and Cantwell on the Commerce Committee for fighting so hard to preserve these critical safety advances in the Senate. A special shout out as well to Senator Duckworth for her experience and passionate defense of these standards. On the House side, we had strong bipartisan support led by the Western New York delegation of Congressman Higgins, Reed, and Collins, and we also wish to recognize the T&I leadership of Congressmen Shuster, DeFazio, LoBiondo, and Larsen for ensuring that this issue never made it into the original House bill. Unfortunately we will never be able to bring my Elly back, but there is some solace knowing that the skies are safer for someone else’s daughter. Now perhaps the airlines can scale back their lobbying budgets so they won’t have to keep raising their baggage fees.”

In the midst of the regional airlines’ push to relax the safety guidelines, the family group continued to point to the regionals’ sterling safety record in the aftermath of the crash and the subsequent legislative and regulatory initiatives. They have led to over nine years without a fatal commercial crash, the longest such period in American history by over three times.

“People can debate the optimum preparation for a pilot all that they want, but the bottom line is that what we have in place is working, and just as importantly, it is making it harder for the shortcut-takers like Colgan and Great Lakes to stay in the game,” stated Scott Maurer of Palmetto, Florida, who lost his thirty-year-old daughter Lorin. “Now that the regionals have hit a dead end in Congress, it is only logical to expect them to go to the Administration directly for a bailout. However, both Secretary Chao and acting Administrator Elwell have made it very clear that they would only take such action if directed to do so by Congress. We are taking both of them at their word, and now we look forward to working with their agencies to bring the Pilot Record Database project to completion. This is another critical step to ensuring that the extremely preventable mistakes that led to the crash of Flight 3407 are never allowed to repeat themselves. As we look ahead to the next Congress, we will continue to remain vigilant and vocal.”
MTF...P2  Cool

(02-22-2016, 02:16 PM)P7_TOM Wrote:  Strange thing is; the same manager was in charge of both Canley Vale and Pel Air investigations; both have serious question marks over the CASA involvement and ATSB ‘reporting’.

Even stranger is the latest rumour that the same person is reported as saying publicly the Rev. Forsyth was either bullied, brainwashed, seduced or coerced into writing a defamatory, scurrilous, untruthful report and providing it to the minister; even thinks the good Rev. should be prosecuted.  All unfounded rumour of course, but even so, it's all passing strange, don’t you think?

But, I do know who I’d believe, if push ever came to shove.

I wonder what the initials are of this person? Is one of them D??

"K' - All here:-


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