The use of the term "system failure" is interesting but it is not clear in what context it is being used.
What is clear is that the majority of accidents are caused by deficiencies with pilot skills and judgement. And many accidents result from a series of factors that may include external influences (e.g. physiological). Even the news report of this latest accident indicates there may be a sequence of events leading up to the accident (overshot runway? Stall/spin?). However, we should not speculate. I reviewed the GFAs business plan and the only ongoing action regarding accident investigation relates to having the ATSB provide a level of accident investigation for gliding. At this time the ATSB will not investigate gliding accidents. However, the ATSB does monitor gliding accidents and they review all accident reports to identify safety deficiencies. If a deficiency is identified, the ATSB will make recommendations to the GFA and others (regulatory authorities, operators, manufacturers or other agencies). For example:- http://www.atsb.gov.au/aviation/rec/rec_detail.cfm?ID=9 or http://www.atsb.gov.au/aviation/rec/rec_detail.cfm?ID=236 Such a review of accident/incident reports is also part of the GFA Business Plan to ensure appropriate safety standards are developed and. Recent examples of this have seen the introduction of lookout notes in response to recent mid-air collisions. Such analysis and dissemination of information is far better than merely making every accident report available to all and sundry. There are also the biennial Flight Safety Seminars that bring safety issues to the forefront. These seminars are open to all pilots to attend and many accidents and incidents are examined at length. As for the summary report in Soaring Australia, with the exception of the reported fatal accident, which was still under investigation at the time, it is not too difficult for an experienced person to understand how a type of accident occurs and what remedial action is needed. And none are "new" accidents (numerous heavy landings, hitting a fence, ground loop, wire entanglement) and the lessons are already known. Robert Hart wrote: On Thu, 2005-04-21 at 13:53 +1000, Christopher H Thorpe wrote: > To say the GFA Executive is lax in the investigation of accidents is absurd. > All accidents are investigated promptly, and the coroner is usually > involved where there are fatalities. Reporting has also improved, > with the last summary of accidents reported in the August 2004 edition > of Soaring Australia. There is certainly a summary - but that is *not* the same as an investigation report. Similarly, the involvement of a coroner does not mean that the lessons the wider gliding community should learn from an accident are actually teased out. If you care to check out the GFA business plan, you will find the investigation of accidents listed as 'on going' as, I understand, has been the case for a couple of years. > It is worth remembering that there are no "new" types of accidents and > lessons previously learned remain relevant today. We just need to > keep reinforcing those vital aspects that can reduce the risk of accidents. That may be true in terms of the accidents themselves (spinning in is spinning in...), but that is not true in terms of the ways we humans come up with of actually achieving that result. Furthermore, as all accidents are examples of 'system failure', it is very important that we work out where the system failed. Then we can correct a system that has gone off the rails and/or redesign the system to avoid that failure mode recurring. Could you please explain to me how the above-mentioned summary of accidents achieves these important safety outcomes? -- Robert Hart [EMAIL PROTECTED] +61 (0)438 385 533 Brisbane, Australia http://www.hart.wattle.id.au _______________________________________________ Aus-soaring mailing list Aus-soaring@lists.internode.on.net To check or change subscription details, visit: http://lists.internode.on.net/mailman/listinfo/aus-soaring
