Of the meat – that in the sandwich. – AP Forum version.
Bear with me a while; ’tis but a ramble, a twiddle if you will; brought to words in the interest of mental health. I purchased a couple of years ago a large slab (6′ x 36” x 2” in old money) of a hard to come by wood – beautiful stuff – but a little ‘awkward’ to work with. I have a project which needs this timber; and so, there was serious work to be done. I have very few ‘machines’ in my workshop (almost none) , which means the use of hand tools – saw and plane – to bring the ‘lump’ to useful boards. The large rip saw need sharpening, a couple of planes needed a tune up and I had to do some some calculations. Hands and mind busy. The sheer pleasure of managing a 110 y.o. rip saw to cut the slab to size, the concentration required to make all the billets 4 square and useful tends to ‘free’ the conscious mind from focused thought; allowing that trapped below to surface to wend it’s way to the fore. Almost a Zen sort of thing; anyway, I now have some wonderful boards, a couple of splinters, a stack of hand tools to re-sharpen and some eclectic thoughts which this ramble prefaces.
It kicked off with an unscheduled short bark of laughter – I was truing the face of a wide board, then the stray thought – ‘the poor bugger never stood a chance’. I was thinking of Martin Scott – Chief Pilot of Ross Air, RIP. The thin slice of meat in a sandwich. The title ‘chief pilot’ may sound grand and important, conjuring up images of steely eyed, seasoned veterans running a tight ship, completely in control of all matters aeronautical, supported by ‘the company’ and backed by the not inconsiderable might of the CASA. It was they who approved the elevation from the ranks after all. Which begs the question – did they ‘know’ the depth of the shit fight he was dropped into?
“Anything is better than lies and deceit!” ― Leo Tolstoy, Anna Karenina
The overwhelming burden of evidence says ‘Yes’ they did; he had a regular coffee date with a CASA FOI (mates) ; there was evidence of a company in free fall, there was major changes in management philosophy, money was scarce, there’d been a suicide attempt, a nervous breakdown, an ex chief pilot disregarded and demeaned, multiple changes to operating policy, check list, check flight procedures, multi crew operations, a like it or bugger off management policy and ‘hatred’ brought into play by the take over company; and: all in all, a major shit storm emerging. This was the inheritance reluctantly accepted. Oh: Patience. I’m getting there.
Think about it for minute. If you took over the CP role, had a mate in CASA, and were struggling to keep the whole edifice afloat – who would you turn to for ‘back-up’? CASA? Forget it. I can, with rock solid evidence provide four separate incidents where CASA, with full knowledge, failed to support a CP when matters were at a critical point. You see a CP gig can be related to a man on a tight rope crossing over a pit of hostile, rock throwing folks, while juggling four balls. Drop one – drop all – and, into the pit you go. No point calling to CASA for help – drop one ball – and they are first to prosecute ‘the fact’. Two stories stand out; one of poor Andy Wilson (fatal) the other still, to this day angers the man at the heart of it. Briefly; he was CP of a company running ‘scheduled services’ (commuter) in mid weight piston aircraft. The company sent a scheduled service into a major airport, full of passengers, crewed by a walk in pilot, not type rated, not within recent practice, who’d never been into the major city airport and was not ‘inducted or checked’. Can you imagine the blow out had there been an accident? I can. The CP (rightfully) went ballistic – operating certificate, insurance, and gods know what else all well and truly buggered. The company simply fired the CP and CASA approved, at 1630 hrs, the very same day a replacement was installed. Some back up eh?
Many seasoned pilots, some of ’em CP’s or ex CP simply do not believe the ATSB conclusion drawn on the Ross Air crash. All firmly believe that what was going on, inside the company at that time was ‘Rum’. Did it contribute to the causal chain? We may never know, but one thing is for certain sure; CASA had foreknowledge of the deep, divisive, on going ‘problems’ the CP faced and yet they failed to support. None of this is probably directly connected to the in flight events – but; boy Oh boy from a holistic ‘safety’ prospective, you have to wonder what the Hell the ‘system’ is trying to achieve.
“If voting made any difference they wouldn’t let us do it.” ― Mark Twain
There, stray thoughts dispatched on the wind, all for nought. Alas, Back to my knitting I wonder though ; have the MH 370 crowd ever considered a couple of points which should interest them? For instance. Many were alarmed, concerned and confused when AMSA was pulled off the search and ATSB got the gig; well, it seems ATSB are beyond the reach of mortal man or his law – untouchable, and immune, by act of bipartisan parliament no less. No matter what. Then, there is the history of ‘omitted’ radio transmissions to consider. Several examples exist where the raw’ transcript or recordings have been modified, denied or even omitted. (See Pel-Air/ Mangalore). The recent fatal mid air collision over Mangalore (Vic) has been muffled and not a living soul can touch the ATSB and make ’em release the whole radio thing. You have to wonder what has been withheld from the MH 370 flight data by ATSB, don’t you. I do…..
From 1:12 –
“..The thing that the committee is struggling to come to is that there have been many witnesses who are pointing fingers of blame at particular incidents. Australia has been a leader in aviation safety for a number of years through its fairly robust adoption of a systems approach, and James Reason is the classic person who has driven that. So, clearly, the actions of the pilot in command and his decisions around flight planning and fuel have a role to play—so do the actions of the company in terms of their checks, training et cetera. But each slice of the Swiss cheese, as the James Reason bowl is often laid out, has the potential to prevent the accident. So the importance that the committee is placing on an incident such as a proactive alert to the pilot that there is now a hazardous situation is not the reason the accident occurred, but it is one of the defences that may well have prevented the accident. If Australia are to remain at the forefront of open, transparent and effective aviation safety then one of the roles of this committee is to make sure that our organisations collectively keep working towards having a very open discussion around that systems safety approach and making sure that each of those barriers is as effective as it can possibly be. That, I guess, is the intent behind a lot of the questioning this morning.
We see that, whatever else occurred, if the pilot had been made aware proactively about the hazardous situation that now existed then perhaps he would have made a different decision. Should he have been there in the first place? Should he have had more fuel? They are all other slices of cheese. We are concerned with this one. The thing we are really trying to establish is, if the ATSB report had had a recommendation that said, ‘This was something that could have prevented the accident. Is it possible to have it put in place for the future?’ then you would have taken action on that as a matter of course. Is that a correct assumption?..“ ― Senator David Fawcett, 19 November 2012.
“..if you look at a safety system holistically—a bit like James Reason and his accident causation model—what we are finding is that each of those pieces of Swiss cheese has been thinned to the absolute minimum that is permissible by law, which maximises the chance of an accident by minimising the options for a pilot who has a malfunction in an aircraft. I guess the request here is that we sit back and look at this holistically, as opposed to saying, ‘Yes, they have met this requirement or that requirement,’ and look at the aggregation of the loss of margin and, therefore, options for an aircrew member who has an issue with an aircraft. Public safety zones are but one element of that whole system” ― Senator David Fawcett, 23 May 2017.
Ref: https://parlinfo.aph.gov.au/parlInfo/dow…fb/0000%22 & https://auntypru.com/setting-the-odds-and-playing-em/
Aye well; no doubt the world has more to worry about at the moment; but, soon or late, there must be a reckoning – Air Services pay their Halfwit over a million a year (plus) to run air traffic control yet we have had a fatal mid air collision – in cloud – by two aircraft operating under the IFR (ref ATSB in three years). We have had a company imploding and yet another three deaths due to CASA insistence on their way or no way – yet failing (dismally) to support a CP out of his depth. Then we have the untouchable ATSB wasting time on a pointless ‘feel-good’ survey which, despite the expense will change sweet bugger all. This all over sighted by a minister who would not know if his arse was on fire. Less you rang a bell and threw a bucket of water over him. Even then…..
Yes, the planet has big problems – but economic recovery begins at home – aviation matters – all of it. So why not use this down time to sort out the government responsibility to those who pay for a world class system i.e. the public. They deserve much better value for the money invested: they really do.
As said, a day ‘on the tools’ concentrating on nothing but making a lump of wood flat, square and fit for purpose breaks focus on the minutiae and brings a wide picture into perspective. Congratulations (and a choc frog) to Phil Hurst for a stellar effort. Bravo, well done, thanks for showing the industry true spirit and real leadership.
But enough: I’m sure I have bored you all long enough. My mates in Alaska would consider 12c at midday swimming weather, but to me, it is bloody freezing. The stove is working overtime, dogs reluctant to leave the comfort of sheep skin rugs, can’t get the cat away from the hearth without getting mauled. Time for a Schnapps, a smoke and feet up on the desk, methinks, while I watch the Rose moon rising.
“Do not swear by the moon, for she changes constantly. then your love would also change.” ― William Shakespeare, Romeo and Juliet