[Peetwo]

CASA & 'just culture'  - Fantasy or fact? 

..Now back to what is IMO the central issue to Ben's article that is now causing debate & contention in the ensuing commentary. 

First the background. Ben Sandilands has witnessed for many decades the administration of the Oz aviation safety system being manipulated, obfuscated, abused, historically tarnished, neglected etc..etc; by a rampant, seemingly untouchable bureaucracy that governments of either colour totally abscond from proper oversight or governance.

So naturally, like much of industry (refer ASRR report), Ben's trust quotient & 'bollocks' alert will be rapidly pinging when it comes to the regulator making comments like..

"...We also have system based on just culture to ensure open reports such as are made to the ATSB and mistakes rectified..."  

Until proven otherwise "just culture" & CASA in the same sentence will be met with much scepticism from an industry (including some aviation journos) that have been bullied, belittled, badgered and embuggerised by the "Iron Ring" big "R" regulator and supporting department for the best part of three decades...

Seaview...Lockhart...PelAir cover-up...Mildura Fog duck-up...VARA ATR bird strike abberration...the list & the bollocks continue - miniscule Chester please take note of what IMO is the most important part of Ben's article:

The new Minister Darren Chester is meeting the grass roots aviation industry in Tamworth this Friday, one hopes before the government goes into caretaker mode on the calling of a general election.

It is an important meeting. It is also important for the Minister to note that his predecessors were treated with arrogant contempt by his department in relation to aviation matters and public safety, and that taking visible control of his portfolio and remembering he is a representative of the people, not unaccountable bureaucrats or corporate entities, is a prerequisite for being held in respect.

 

MTF...P2

Ps

VH-NJI in-flight fire damage



Source: Jason Grimmett

Gotta wonder where all those bits happened to land -

Following on from my post above the commentary & mudslinging between Ben & Fred continued until this...

Ben Sandilands
May 7, 2016 at 8:30 pm
Fred,
CASA isn't ever justified in ignoring the law, as it did in the Pel-Air saga, or treating the executive branch and the people of Australia with arrogant contempt. It's statement in relation to Cobham was a total nonsense, in that it completely contradicted its position on Tiger Airways.
This is an agency that doesn't have the capacity to overhaul aviation regulations even to its own timetable, and let 15 people die in the Transair disaster because it knew the airline was dangerous yet elected, as per its Senate committee evidence, to take no action, contrary to its obligations under the law, and without warning the public.
You are in the wrong place if you think I'm going to ignore its resolute unwillingness or helplessness when it comes to being an effective safety regulator.
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Fred
May 8, 2016 at 11:36 am
Nobody asked you to Ben, but how about a little balance?
CASA's failings are well documented. What do you propose as a solution to improve the safety culture in Australia? On the one hand you imply that James Reason's methodology should merit more respect, and yet on the other you seem to advocate the punitive culture that Reason and others reject.
I'll reframe the question I asked earlier: Do we want a punitive culture that is likely to encourage individuals and organisations to hide their mistakes; or do we want a culture that encourages open and honest reporting, but at the same time does not tolerate wilful violations or reckless behaviour? Surely the answer is obvious.

 


Ben Sandilands May 8, 2016 at 12:58 pm Fred, I'm on the side of those who want an accountable culture in the public administration of air safety in Australia. An administrative branch that is subordinate to and the servant of the executive branch. In other words, one that is appropriate to a parliamentary democracy, not some tin pot third world state. What do you stand for we might wonder? Just a string of excuses for practices that undermine air safety. If you were to better inform yourself about the current situation in this country you'd know that Australia has policy settings in aviation that are contrary to those endorsed by ICAO and the NTSB and FAA in some areas, and put commercial expediency above all other considerations, including the direction taken by James Reason. 



Fred

[url=http://blogs.crikey.com.au/planetalking/2016/05/02/cobham-jet-caught-fire-after-company-failed-to-properly-repair-an-engine/#comment-39342]May 8, 2016 at 1:24 pm

I am very well informed with respect to safety regulation in this country, thank you. As a professional pilot, my safety depends upon it at least as much as yours and other members of the travelling public. My comments were not aimed at making excuses. They were intended to put a few things into perspective with a view to finding a better way forward than constant harping that does nothing to improve safety.

You have made it abundantly clear that dissenting opinions are not welcome at Plane Talking. That is a very great shame, given the limited discourse on aviation matters in the media here in Australia. Perhaps you'll be glad to know that I will not be adding my comments to any further discussions.

And so the to & fro, quid, pro, quo inevitably drifted to an end ; that is until P9 chimed in with this: 

Sam Jackson
May 10, 2016 at 7:08 pm
Now, when everyone has finished banging their drums; can we have a look at the realities? For example a flawed design which requires constant repair to peripherals. This engine section (component) has, in what, 10 short years often needed ‘repair’. Clearly, if the lug is in need of constant monitoring and a repair protocol, the underlying reasons for that need examination. I think we all have a fair idea of what happens within and the pressures it’s subject to of a ‘combustor’. Furthermore – if a 0.002 thickness of metal is the difference between flame in and flame out, then there is an inherent problem in the design specification.

There may be flaws in the system for checking and recording repairs, there is in every system. But – reality is a prospective buyer cannot, nor will a survey engineer on a ‘pre-buy’ inspection take out a micrometre and check the thickness (or lack thereof) of every ‘skin’ in the aircraft. The ‘grinding pass’ may well have been a couple of thou too much – but how could Cobham, or anyone else for that matter have known? The lug ‘repair’ prescription is a result of inherent faults within the combustor liner design. If, indeed there is an existing design fault, then how is it to tracked back to the designers weight/ cost allowance tolerances, let alone to the apprentice welder with a grinder. No: this dog won’t hunt – what of cracks in the combustion layer, which lead to lug failure, which lead to fine tolerance grinding, which start engine fires? Only one place to look foe answers.

To which Dan Dair replied:

Only one place to look foe answers.

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Dan Dair
May 11, 2016 at 6:59 am
Sam Jackson,
Now that you’ve got-down off your own soapbox….. (joke)
Can I ask a question of you, which I alluded to with Fred.?
How big a problem has this particular issue been with these Honeywell engines.?
The fact that Honeywell had an inspection regime in place AND had requirements specified for welding repairs would imply that the problems surrounding the liner & bosses is well-known to the manufacturer.?
On the other hand, the ATSB report appears to suggest that there isn’t any significant history of actual failures which relate to this engine-type.?

NB. I agree completely about the 2-thousandths tolerance-deficit. Sure, it’s out of tolerance, but as I said earlier, it’s flown for ages with no apparent problems. The idea that the 2-thou’ makes all the difference is a bit rich to me.? That statement would imply that it is inevitable that the liner MUST fail if it is out of tolerance.?
Surely if that IS the case, it would make more sense to have made the liner a couple of millimeters thicker in the first place, or perhaps they ought to have specified that welded repairs were unacceptable ten or more years ago, when this particular problem was already apparent.

I then followed in with quoted parts of my post above, to which finally (to this point ) P9 replied to Dan Dair (& myself) with this excellent & balanced posted comment:

Sam Jackson

May 11, 2016 at 7:26 pm
(Smile) – Nay, not a soap-box Dan; ‘tis but a small stump. The ATSB investigator has, as P2 defines it, not done too shabby a job in this report. Honeywell had and still have a procedure in place to deal with a ‘known’ potentially weak area; and, that procedure has stood the test of time. I have no doubt that amendments now in place will adequately cover any other potential trouble spots their skilled engineers and experts may discover. Company reputations and profits depend on the ‘manufacturer’ getting it right – every time. The pressures and temperatures within the combustion section of a modern jet engine are insane; these engines have been in service a long time now and there can be little doubt the repair, done when required, as specified, has been effective. ATSB do reflect this in their report; mark you they have no skin in the game; their report also reflects that. Hopefully, Greg Hood will be able to stop the downward trend and PC outcomes we have seen the last half decade.

But CASA – well that is a horse of a different colour. Personally, I don’t believe there is much in this one incident, to get them reaching for the big R book and hammering the company. It could even be that the company was as much sinned against as it was sinful. Caveat Emptor has long been a hard held tenet of aviation traders, for bloody good reason. No, the beef is with the cynical CASA point scoring, by claiming, all of a sudden, that a ‘just’ culture is in place. Bollocks. Just when it suits and only when it suits is much nearer the truth. Close observers know that this is just another cycle in the no change to policies of strictly no liability, responsibility or accountability. It has been thus for at least three decades I have witnessed. This will not be allowed to change under the current lunatic running the asylum.

So, we have a known, high stress engine area which, occasionally, needs careful, concise, proper repair. We have a manufacturer doing all the right things. We have an ATSB report which, in the main, is acceptable. Then we have the CASA ‘touchy-feely’ response. Now a cynic would (quite rightly) say that CASA would not dare upset a company like Cobham, in any event. The notion of annoying a big hitter like Cobham – when they probably have the ‘law’ on their side becomes unthinkable. A cynic could say that ‘just culture’ is just buzz words, written on the dunny walls, but Gibson is silly enough to use it, after a non event to score much needed Brownie points. Two thou’ does not a law suit make – IMO. Right then; off the stump and back to my knitting, having spent my two bob as best pleased me.

  
MTF?- Yeah I reckon...P2