Lockhart River reflections

In reporting on the events and actions leading to the accident, the Coroner based his findings on all of the available evidence, including that given by the captain of the accident flight at a previous inquest into another accident.

This telling evidence had not been discovered prior to the inquest, and it had therefore not been considered by the ATSB during its investigation.

The Coroner stated that “I consider that the evidence indicates that midway between the intermediate and final approach points, Mr Hotchin abandoned the RNAV GNSS approach and as a result of sighting the ground, determined to get beneath the cloud cover to conduct a visual approach to Runway 12. ” His findings continued with discussion of why the captain may have acted in this manner, and included a rejection of CASA’s submission that loss of situational awareness played no part in the accident.

Perhaps most alarming was the Coroner’s finding, in relation to the question of why the crew had not been alerted by the GPWS, that “there is evidence that Captain Hotchin had on other occasions de-activated it. ” The report also highlights differences between the ATSB and CASA which were severe enough for the Coroner to recommend to the Minister that he “consider engaging an external consultant to assess whether high level intervention is warranted. ” Some tension is bound to exist between the investigating, and the investigated bodies just as tension can also be seen in the relationship between the NTSB and the FAA in the US. However, the fact that the Coroner felt moved to report on the rift between ATSB and CASA suggests that this was not just creative tension.

In the case of the Lockhart River accident, the tensions presumably arose because the ATSB in its report raised a number of “contributing factors” and several “other factors” relating to CASA’s processes. Taken together, these factors do not portray CASA’s surveillance in as good a light as CASA might have wished. But the ATSB is “an operationally independent body . . . entirely separate from transport regulators and service providers” with the role of “independently investigating, analysing and openly reporting on transport safety matters. ” It has to report on what it sees. That is only to be expected, and at times takes considerable courage.

Should CASA have been as miffed over the criticism as the Coroner reported? Clearly in the opinion of the Coroner, the answer is no.

However, one should try to see the situation from CASA’s point of view. Regardless of its strengths and weaknesses, CASA has been a political football for years, and a target for much unfounded public criticism in the media.

It is perhaps understandable that it should therefore be highly sensitive to criticism, and should try to defend itself vigorously. This is particularly so when one recalls that the media appeared to be portraying the accident as CASA’s fault, which is not what the ATSB reported.

However, CASA’s submission that “responsibility for the crash started and ended in the cockpit; that there was nothing that any other individual or organisation could have done to prevent the crash,” was also not true.

The pilot’s actions on the fateful day did not happen in a vacuum. They occurred within, and partly as a result of, the culture within which he worked. Within a positive safety culture, aberrant behaviour should be formally identified and corrected. The fact that it wasn’t in this case was ascribed by the Coroner to a failure by the company “to adequately monitor its pilots and to take steps to ensure that they were all complying with its policies,” something which probably should have been identified and corrected by CASA. But that is not to say that CASA was in any way responsible for the accident. Just that one of the defences that CASA could and arguably should have provided was not there.

I recently came across a definition of safety culture which I believe was coined by the prominent international safety expert, James Reason, and which gives us as an industry something to which to aspire: “The safety culture of an organisation is the product of individual and group values, attitudes, competencies, and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation’s health and safety programs.

Organisations with a positive safety culture are characterised by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures. ” Our industry, like many others, depends on safe operations for its survival. Safe operations are the natural result of a healthy safety culture, and in a healthy safety culture there is no place for accepting unacceptable behaviour.

If there is anything positive to be gained from this tragic accident, and from others before it, it is to recognise the critical importance of a positive safety culture, in both the regulator and the regulated, in order to provide the best defence against future accidents. o Australian Aviation is proud to be the official supporting journal of the Regional Aviation Association of Australia. The views in this column are those of the RAAA, and not necessarily Australian Aviation’s.