Sharing the Experience

What part does punishment play in air safety? How does the threat of punishment further the free exchange of information?

These two questions have been passing through my mind over recent times. The matter was brought to a head by recent reports in the daily press. These concerned a pilot who had been charged by the Federal authorities and subsequently fined in a Federal Court for breaches of the Air Navigation Act, resulting from a report that he had submitted. The report dealt with a minor mishap that had occurred whilst he was taxiing a light aircraft. In all probability, had the pilot not made that report, he would have suffered neither the social stigma nor the financial penalty. The only sufferer would have been air safety.

Air safety experts have long recognised the importance of a free exchange of information concerning accidents and incidents. Experience must be shared. When misfortune befalls one member of the aviation community, the fullest details of both cause and effect should be passed to other members to save them from falling into the same trap. That is how the system should work. What is going wrong? Let us take a look at a couple of examples. .

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In 1966 Ansett-ANA lost a Viscount airliner due to structural failure following a catastrophic wing root fire. The aircraft crashed outside Winton, Queensland with the loss of all on board. Only then was it discovered that a similar wing fire had been experienced on a Viscount in the Caribbean. Perhaps fortunately, this fire had occurred while the aircraft was on the ground, so no casualties resulted. Less fortunately, news of this fire was not passed to other Viscount operators. Thus when the same circumstances occurred in flight, the resulting crash was inevitable. The experience had not been shared.

Some years ago, a Boeing 747 descended below its cleared altitude during an approach into Nairobi. As a result, it came closer to making catastrophic contact with the 5000 feet above sea level terrain surrounding Nairobi than those on board would have liked. On arrival the captain of the aircraft, realising safety had been compromised, made a report recommending an enquiry be held to establish the reason for the error and to prevent reoccurrence. How did his company reward him for his honesty? They immediately dispensed with his services as an example of what would happen to anyone else who made a mistake – and owned up! One can imagine the effect this action had on the number of voluntary reports submitted by his fellow pilots. Once again the experience is not being shared.

All who work in the aviation industry could doubtless come up with similar situations, so a little confession would not seem out of place. Back in the nineteen sixties, those good old days when avgas was under forty cents a gallon, your writer was employed as a flying instructor at an Australian capital city secondary airport. On the day in question, the flying school was conducting a streamer-cutting competition. To the uninitiated, this involved climbing to a suitable height over a large body of water, throwing a toilet roll out of the cockpit window and cutting the resulting streamer three times with the aircraft. The pilot who made the three cuts in the shortest time was declared the winner. All very well, except that from time to time, instead of a couple of hundred feet of streamer floating gently down, all one got was a bunched-up little cloud of unravelled toilet roll about three feet across. This constituted a ‘no target’ and another streamer was released.

On this occasion, after three ‘no targets’, your correspondent lost ·patience with the exercise – always a bad move when connected with aeroplanes – and decided to attack the bunched-up streamer. Being in good flying practice at the time, I hit the cloud of paper on the propeller spinner, expecting to see tiny pieces of paper scattered to the four winds by the whirling blades. Instead, all the paper disappeared as if by magic, under the engine cowling and onto the hot cylinders. Fortunately, the airfield was not far away and the paper did not have time to catch fire, although it was smouldering pretty well by the time we lifted the cowling and removed it. Did your correspondent report such a hazardous occurrence to the appropriate authorities? The answer is no. Quite frankly I was too embarrassed, although the story has been well aired over the years in the places where aviators like to meet and talk. Would I have been punished for my hasty actions? I don’t know, but the experience should be shared.

Should punishment follow a genuine mistake or a human failing? Judging by the statements of the late Sir Donald Anderson, known to the writer as a total aviation person of both strength and compassion, it would seem not. Sir Donald offered immunity from punishment to those who reported air safety incidents, as long as there was no suggestion of deliberate disregard for the law or culpable negligence.

This policy has been restated by his successors, both Mr Charles Halton and the present Secretary of the Department of Aviation, Mr C. W. Freeland. I hope this policy will stand the test of time and the Experience will continue to be shared.

This is expected to be the first of a series of articles on an air safety theme. If any readers have contributions along the lines of the ‘confession’ contained herein, we would be pleased to include them in future articles (anonymously if necessary). We consider this to be AUSTRALIAN AVIATION’s contribution to sharing the experience.

 

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