Hi Mike, Mike Borgelt in particular, and All,
Very nicely put.
I note in particular your comment "...and the amount of knowledge gained from
NZ investigations is not significantly higher than here." I suspect that you
could widen "NZ" to "Worldwide".
At the risk of seeming outrageous, let me say that to the ATSB and its previous
incarnations, investigating glider accidents is, within the bigger picture of
accident investigation, "just plain boring".
How so? Let me explain.
Unless I am missing something, there are basically only two factors to any
gliding accident - mechanical failure, or pilot error( or incapacity). In an
ultimate analysis, everything can be reduced to these two fundamentals. [There
is no doubt that these fundamentals also apply to any accident scenario where
human beings are involved.]
Some pundit will no doubt be able to quote the "exact" figures for gliding, but
in gliding accidents MUCH less than 10% of accidents can be attributed to
mechanical failure. I will leave it to you to work out what the remainder is
allotted to! ....... However, do not jump to conclusions. In (unfortunately far
too many cases), WHAT happened is quite easy to determine. WHY it happened
cannot be determined at all! Nevertheless the fundamental premise that I have
posited above must apply.
Gliders, in comparison to say modern airliners are relatively simple machines -
just ask the boys in South Africa who developed the JS1.They are reputed to
have put in over 70,000 total hours to get to official Type Approval!
So, in a few instances of gliding accidents there is a mechanical problem. As
gliders are such simple machines, any mechanical failure should be relatively
easy to determine. This does not require the input of the ATSB. As Wombat has
said, the ATSB generally leaves it to either one of the other two entities who
CAN legally investigate - the State Police, or the State Coroner.
If you are particularly observant, you will note that neither Wombat nor I,
have mentioned the GFA in this context. Legally they do not have a role. In
practice they are generally requested to supply expert advice to the
Investigating Authority. Apart from anything else, this keeps the GFA "in the
loop".
[It is a digression, but it would seem in fact that these two bodies
Police/Coroner co-operate. Maybe some legal eagle might be able to explain just
what are the current arrangements, which may possibly vary from State to State.
I posit that in theory each one of the 3 entities is able to carry out an
independent investigation if it so chooses?]
So much for mechanical failures.
What about Pilot Error?
Well pilots have been crashing, and in many cases dying, since man took to the
air. Every possible means of crashing has been explored from that time until
now. I suspect that all the possibilities for human error were exhausted long
ago: Hence the lack of ATSB interest.
As a result of these experiences the GFA produced a Manual of Standard
Procedures. You are of course perfectly free to ignore the accumulated wisdom
of ages, as set out in this document and taught by every accredited instructor,
but you do so at your peril.
Regards,
Gary
----- Original Message -----
From: Mike Cleaver
To: Discussion of issues relating to Soaring in Australia.
Sent: Wednesday, April 25, 2012 4:40 PM
Subject: Re: [Aus-soaring] GFA Site/accident
John and others
The ATSB has a system for classifying accidents and incidents - see on their
web site http://www.atsb.gov.au/about_atsb/investigation-procedures.aspx and
http://www.atsb.gov.au/about_atsb/investigation-procedures.aspx#fn2
- the latter identifies what the various levels of investigation involve in
terms of ATSB resources.
Sport and recreational aviation accidents - even fatal ones - are almost
never accorded a classification higher than 4, which means that after the
recording of various factual information, the investigation is either carried
out with one or two ATSB investigators or may be referred to another agency. In
the case of a fatality this is often the police force in the State or Territory
where the accident occurred - either for potential crime investigation or more
likely for the Coroner to investigate. The Police/Coroner will usually seek the
assistance of the GFA in the case of a gliding accident, but the GFA generally
regards itself as under-resourced to carry out aviation accident
investigations, as no funding is provided from Government sources to train and
equip investigators.In any event the funding provided by Government to the ATSB
is such that most accidents are not investigated in any level of detail, unless
they involve passenger transport operations in large or medium capacity
aircraft. The days when ATSB investigated sport aviation accidents to any
greater extent than this ended over 20 years ago, and are not likely to return.
While gliding fatalities are investigated by TAIC in New Zealand, that is not
the case here, and the amount of knowledge gained from NZ investigations is not
significantly higher than here.
A further factor that militates against the GFA conducting and publishing
accident reports is the fact that, unlike Government agencies, the investigator
may be held personally liable for the way findings are reported, and challenged
by relatives of the deceased or others who have suffered personal or property
loss, or by survivors of the event who may claim some degree of negligence
(read financial compensation for some assumed fault by the GFA or its members)
or defamation as a consequence of the reporting.
This has the potential to affect all of us, whereas an ATSB investigation is
rarely handled this way. Note that this is a fact in spite of the acknowledged
purpose of accident investigations being to prevent recurrences and identify
procedures or training that may assist in this goal: accident investigators do
not lay blame for occurrences (and sometimes it is hard to read into their
reports any reference to even obvious breaches of the law or safe operating
procedures).
This is why we have to wait so long for a Coroner to produce a report before
we can make changes to the system, especially where training or procedure
changes are involved, or airworthiness actions.
Wombat
On 25/04/2012 12:09 PM, john.mcfarlane wrote:
I would have thought that this is a mandated reportable incident via the
Fed Gov body delegated with that authority - ATSB.
Will there be a formal report from the ATSB?
----------------------------------------------------------------------------
From: gstev...@bigpond.com
Sent: Monday, 23 April 2012 4:17
To: Discussion of issues relating to Soaring in Australia.
<aus-soaring@lists.internode.on.net>
Subject: Re: [Aus-soaring] GFA Site/accident
Re accident prevention, in this instance we will have to wait on the
Coroner's report, which I would not expect any time soon. It may be able to
pinpoint a problem, and if so we - that is the collective we - can then act.
However I am not holding my breath on this one.
Regards,
Gary
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