air safety

Nov 26, 2012

ATSB ‘leads’ air safety into a retreat from Reason?

The Hansard record has caught Australia's air safety authority diminishing the role of James Reason in crash causes, raising more questions about how far it will go to cover up deficiencies in CASA's oversight of air ambulance operator Pel-Air

Ben Sandilands — Editor of Plane Talking

Ben Sandilands

Editor of Plane Talking

Has Australia been dragged back toward the dark ages in air accident investigations in order to cover up gross deficiencies in the performance and professional integrity of CASA, the air safety regulator?

There is a section of the testimony given by Martin Dolan, the chief commissioner of the ATSB, the investigating authority, to a Senate inquiry last week that suggests this is the case.

The Senate committee concerned was inquiring into the final report issued by the ATSB on 30 August into the ditching of a Pel-Air Careflight air ambulance charter near Norfolk Island on 18 November 2009.

This is the critical passage of that hearing, last Wednesday, as reported in Hansard, which can be found in full at the inquiry’s web page under transcripts.

Mr Dolan: We see our job as a different job from CASA’s. The special audit was in relation to CASA’s views about how Pel-Air complied with regulatory provisions. That is their responsibility as the regulator. We wanted to understand what risks existed in the system as it stood that needed attention and were ongoing risks to safety. We did that through our investigation and the material we acquired.

Senator XENOPHON: Given what you have conceded—that the special audit report contained information that could go to systemic issues, the sorts of issues which were raised very well by Senator Fawcett at previous hearings—could that have been relevant for the purpose of the ATSB’s final report?

Mr Dolan: That is possible. The only point I would make in response to this is the broad context in which we were undertaking our investigation. There were a range of things. If we want to go to Professor Reason’s model of investigation—though we think we have come a long way since Professor Reason’s initial work in the 1990s—there is error and there is violation. While the focus of our investigations is on error and understanding error—how to prevent it, how to detect it and how to deal with its consequences—there was also in this case an element of what, in Professor Reason’s model, would be viewed as violation; and that is principally the responsibility of the regulator.

Professor James Reason is the UK psychologist whose work in the causes of preventable accidents, in aviation, and industry and health care more broadly, both revolutionised and underpins to this day the methodology of air safety investigations and safety enhancement. He is often credited for enunciating the Swiss cheese model for accident causes, where a range of issues, each of them insufficient to cause a crash on their own, align, like the holes in the cheese, allowing a disaster to occur.

To have it demeaned in the manner that it was in the Senate inquiry, without any obvious reason other than an unannounced policy retreat by the ATSB in order to protect CASA from being exposed as derelict and incompetent  in the discharge of its duties of care and oversight is to be blunt, a national disgrace and embarrassment.

The Minister responsible for both CASA, and the supposedly independent safety investigator, Anthony Albanese, is a busy man.  He appears to be too busy to deal with these issues, other than to brush off through a spokesperson any suggestion that the ATSB ought to have, at the least, told him it was changing its supposedly world leading methodology to avoid issuing safety recommendations, the function which the rest of the world, and Australian air operators, actually rely upon to be alerted to issues which may be of wider relevance to their activities than Pel-Air alone.

Those unannounced policy changes by the ATSB resulted in a report which makes no reference to a special CASA audit of Pel-Air that found it unsafe in its Careflight operations at the time of the accident through multiple breaches of the applicable aviation rules.

The focus on errors rather than violations by the operating company also produced a report that cast no light on fatigue issues, or the failure of air traffic control to pass on a warning of a serious deterioration in forecast conditions for the arrival of the jet at Norfolk Island, or pilot fatigue, or the suitability of the jet to even embark on the mission it was flying, or the failure of all of the safety equipment on board.

It makes no reference to the disclosure in the CASA audit to the lack of fuel planning guidance by the operator Pel-Air for the Westwinds in its fleet, nor to glaring discrepancies between what CASA had discovered about the operator in previous audits compared to what it uncovered after the loss of the jet in question.

The report effectively suppressed disclosure of significant concerns within CASA over regulatory confusion as to whether such flights should turn back or press on when conditions deteriorated on charters such as the one that crashed.

The real danger in the situation touched upon by Dolan however, is that Australia has allowed its two aviation bodies to trash the standards of disclosure, enforcement and investigation that its public, and its air operators, and the rest of the world wide aviation safety community, previously took for granted.

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4 thoughts on “ATSB ‘leads’ air safety into a retreat from Reason?

  1. Mark Newton

    Dolan’s attempt to distinguish between “error” and “violation” reinforces CASA’s move away from Reason’s model, which has been underway for quite some time.

    The rhetorical expression of the New World Order is “Just Culture,” which you can see bandied about quite a bit, particularly in the way CASA approaches smaller operators, where it’s emphasised as a rationale for emphasis on training and management of human factors.

    The theory goes like this:

    Errors are understandable and inevitable, and addressed in the now traditional way via Reason’s model.

    Alongside errors, however, are cases where humans involved in safety systems have understood the rules, and have made conscious decisions which have had the effect of violating them. A common example used to illustrate that is the hypothetical pilot who crashes into a power line while doing a low pass over his girlfriend’s house: Fully aware of the rules and safety implications, but deciding to ignore them.

    The sports aviation bodies have been increasingly been all over this in recent years. RAAus now has human factors modules incorporated into its training syllabus well in advance of anything that a CASA pilot will encounter (to the extent that CASA license holders wishing to acquire RAAus credentials are now required to undergo additional training)

    In a “just culture,” errors would be addressed through training, enhancements to safety systems, etc; But violations would be punished, because it isn’t “just” to have people running around breaking rules all the time without some kind of regulatory response. Moreover, there are very few safety lessons to be learned from violations that haven’t been learned thousands of times already (“Oh, look, yet another idiot hit a power line and turned himself into a lawn dart.”), so the safety messages arising from them are muted and the punishment is emphasised instead.

    It seems to me that in the Pel-Air case, the ATSB has decided that the pilot was aware of rules pertaining to refuelling, oceanic weather, selection of alternates, etc; and chose to proceed anyway.

    So in the “just culture” model, that’s a violation, not an error; and ought to be punished, not understood. The fact that the pilot made the decisions he made in the context of his employer’s safety systems (or lack thereof) loses importance.

    It seems to me that if this continues, we’ll be on a path towards the bad old days of holding people criminally liable for accidents/incidents. The effect of that on safety is well understood: Liability-conscious individuals will neglect to report incidents, no lessons will be learned from unreported free-kicks, and accident rates will consequently increase.

    If the Government is serious about its “just culture” efforts, it needs to apply a bit more maturity and depth to its execution. Reflexively dumping on pilots following multi-causal accidents isn’t going to get us anywhere useful.

    – mark

  2. [email protected]

    What is even more concerning in the retreat by ATSB is that several of the signal publications by Professor Reason are co-authored by Dr. Robb Lee, the former Director of Bureau of Air Safety Investigation, BASI, the predecessor of the ATSB.
    Pioneering Australian work has been discarded.
    Bill Hamilton

  3. monty

    Agree with Mr.Newton. In fact, it is not just within smaller operators, but within the airline industry too, that CASA seem intent on pushing the ‘Just Culture’ -( ” you just made a mistake, you’ll just be sacked” )The effect is that safety departments are tending to conduct safety investigations in a punitive manner – lets hang the crew, then ask questions.

    No one is beyond making errors, so we do our best to mitigate the causal factors, by establishing better policy and procedures. This should be the preserve of a safety department – “Lets find out why an incident occurred, and what can we do to prevent same/similar from occurring again.” And this is where the ATSB needs to lend support.

    Unfortunately, Australian corporate management is suffering from a false sense of “can anyone pin this on me, now or in the future” such that sensible decision making has been abandoned..

    God help aviation in this country.

  4. Geoff

    The four outcomes from current attempts to define a Just Culture are considered behaviours not outcomes
    1. Human Error
    2. Negligence
    3. Recklessness
    4. Malicious Intent

    However even Human error is split by determining whether the person has a history of human error. Only a lack of all the above and no history or error will save you from some degree of blame.

    All of this came from James Reason but it is separate to his famous Swiss Cheese theory and in it he tries to determine where the line should be drawn in the Just Culture. Negligent Behaviour for instance can be something that a reasonably skilled person would not have done, such as driving into your neigbours fence and knocking it over. Reckless Behaviour is doing something that would be obviously wrong to a reasonable person, such as driving well in excess of the speed limit, losing control of the car and knocking the fence down.

    Obviously whether or not an action is negligent or reckless is very much in the eye of the beholder and of course can be influenced by the degree of self interest that beholder might have.

    Without totally impartial safety agencies and company managers wholly committed to a safety culture (not only a just culture) safety will go backwards

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