TGIF on the AP Forum: 21/04/23

First this week’s #SBG: Warning! – Rant follows

“While we thank the ATSB for its thorough investigation, we are incredibly frustrated that it has taken 2 years and 9 months. This may have a significant knock-on effect in holding people to account for Amber’s death, as Work-Safe must commence a prosecution within 3 years of an accident under the then applicable Occupational Safety and Health Act 1984.

‘Safety’ – we keep hearing the word bandied about; we hear it used in all manner of varying context and yet one man’s version of what is ‘safe’ may be very different to the next. Getting out of bed in the morning can be ‘dangerous’ depending on many variable factors and yet the vast majority of folk just hop out every morning without a second thought, wander down stairs (potential risk) plug in the kettle (potential risk) amble into the bathroom (potential risk) hop into the shower (higher risk) etc. From cradle to grave, in almost every situation there is a potential, on a varying scale of risk that a wheel may come off the wagon. The reasons behind the where, when, how and ‘why’ that happens are many and infinitely varied, and yet ‘stuff still happens’. So, what to do? Where do ‘safety’, logic and common sense meet? Do you go to the beach wearing a rain coat in case a passing seagull unloads on you? Murphy declares that the moment you take the raincoat off – that’s when the bird will strike. There is ‘risk’ – always; it goes hand in glove with life. Mitigating the risk to an acceptable level depends very much on the individual risk and how it is assessed, by the person potentially at risk. Here we must look at conditioning, training and education.

Short digression – A simple example, my young nephew needed to clean out a housing (groove) to fit a part of his saw horse. Tool required – a 25 mm, surgically sharp chisel of unfamiliar weight and length – with no muscle memory to support the effort. “NO” I bark as he picks it up: – education followed, supervision and advice given as he progressed; it took three reminders that he had fingers directly opposing the direction of travel. Slowly the ‘safety’ message delivered sunk in. But I’ll bet good money that one day, in a moment of distraction, a sharp chisel will reinforce the message; hopefully without serious consequences. We shall see. The point – is the risk mitigated, eliminated or simply latent? The percentages chances of a cut needing a stich or two, at some time in the future can be converted into a short odds bet.

My ramble – my opinion, – but it seems to me that it is how we work backwards from a conclusion (or worst case scenario) to identify the elements in any event which caused harm or injury from the very first item, through to the last; the event chain. This helicopter in WA for example. The thing has shaken itself to pieces, airborne and claimed two lives – fact. It has taken two years and nine months for the investigation to be published. That, stand alone is cause for great concern, particularly given the three year statute for filing claim and case to answer; but that will keep for another day. The ‘big’ question is could this event have been avoided? The short answer is a resounding Yes. The bigger and more important question is why it was not prevented. There was ample warning – there was ample information relating to ‘vibration’ and the procedure for determining and eliminating the mechanical fault. There are laws which demand compliance; there is a huge official ‘safety’ watch dog and attendant satellite agencies; there are trained pilots, trained engineers and a raft of common sense lore which should have prevented the aircraft from operating until the ‘problem’ was fixed. Yet no part of the expensive, extensive, complex ‘safety’ system stepped in early and prevented the event.

“The ATSB’s investigation report notes the helicopter’s two previous flights were conducted by two separate pilots (including the accident pilot, who was also the helicopter’s owner), who both reported experiencing vibration in the helicopter’s tail rotor pedals.”

Should that aircraft have ever been allowed to carry passengers before the ‘vibration problem’ was eradicated? _ Simple question, would you drive your car into traffic at speed with the wheel bearing vibrating, or the engine vibrating or a wheel badly out of balance; with your children on board in a heavy rain storm? Your risk, your responsibility and it must be you who carries the burden of blame for any and all injury or damage. The insurance company would eat you and your legal team for breakfast, not even spitting out the bones. Due to the ATSB tardy delivery of report (once again) the parents of the dead child have only months now to sort out their ‘legal’ position and file it. Bravo ATSB, well done, proving once again, that ATSB is about as much use to timely ‘safety’ advice as three men away from home at harvest.

There – rant over; apologies to the offended; but, seriously what the Hell are ATSB becoming – a PR outfit? If so for whom? Not the minister – she is safely at arm’s length, twice removed and could not care a button.

Selah….

Next from the AOPA Oz thread: AOPA AUSTRALIA LIVE – TUES 18TH APRIL 2023