One of the concepts of a just culture is that the participants don’t hide behind it.
The thing with cultures is that they are, uhm, cultural, which means that they are hard to shift, and rely on how people act almost unconsciously on a daily basis. If the boss is a big-ego autocratic pilot who thinks CRM means Captain Rules Minions, forget it.
To make them work in real life requires hard work and takes time. Change aversion, big egos, lust for revenge, etc. all work against a just culture.
Dave_Phillips wrote:
One of the concepts of a just culture is that the participants don’t hide behind it.
Which means that it only works in the same ideal world where communism lets everybody lead a happy life. But I repeat myself.
In the healthcare environment, ‘incident reporting’ systems inspired by aviation seem to be used primarily for purposes of bullying, back-covering and coercion. One thing in their favour: the people tasked with dealing the reports seem to know this and as a tactic I don’t think it generally works – often the reports seem to simply vanish into the ether. Unfortunately I often feel that when someone’s made an error, it would be useful for whoever becomes aware of it to discuss it with them. Obviously this can be an awkward thing to do and I sometimes feel that teaching opportunities are missed when somebody simply fills out an incident form instead. Another example of a healthcare failure in implementing a ‘just culture’: junior doctors within the UK have a duty to whistleblow but are not considered to be employees and so are not covered by whistleblower-protection legislation.
So, believe me when I say I can understand why you are sceptical about a ‘just culture’. I can well see some of the barriers towards implementing one as my own industry has so far mostly failed to do so. On the other hand, the police failed to procure most of the AAIB documents relating to the Shoreham case: https://www.gov.uk/government/news/shoreham-high-court-judgement as the judge argued that there would be a serious and obvious “chilling effect” which would tend to deter people from answering questions by the AAIB with the candour which is necessary when accidents of this sort have to be investigated by it. So where there’s a will, ‘no-blame’ safety investigation is achievable. But it’s clearly something that has to be fought hard for.
Why would that be? “Minimum display altitude” means exactly that. And that “low pass” was not even over the runway.
Look at CAP 403 – the document guiding airshow displays within the UK. It states that there are separate display heights for aerobatic figures and for ‘flypasts’. It also says that aerobatic figures may lead into flypasts below the aerobatic display height once safety is assured, though it doesn’t specifically address aerobatic figures following on from flypasts. Displays including flypasts can happen over the sea, so there’s clearly no requirement for a flypast to happen over a runway.
Again, I have no firm views on the rights and wrongs of this case but I’m reluctant to jump to conclusions.
At Shoreham, you can’t have a display over the sea because it would be too far away for the crowd to see. Also you would not be able to sell tickets (because access to the beach can’t be controlled) which is the whole point of this RAFA charity event.
I haven’t read the long report but it may mention that there have been recurrent problems at Shoreham with people crowding just outside the area for which tickets are sold (the tickets are not that cheap). The event organisers obviously don’t like this and have gradually blocked these out (e.g. the riverbank was eventually shut off) but I believe that the area where the ground contact occurred was one of these problem areas. There is a pic online showing the plane sliding along the ground, with several people standing right in front of it who would have been dead a second or so later, and they were definitely in the aforementioned spot. This may be one consideration for future shows but I don’t see what the organisers can do about it. And obviously the people sitting in their cars on the A27 were not spectators anyway.
Yes there are separate authorisations for the heights of flypasts and for the initiation of aerobatics; something like (from vague memory) 200ft and 500ft in this case.
what_next wrote:
How would you know that?
I’m only referring to what you wrote. You said you have “tried”, yet your boss fire people at the earliest convenience as a result. That is not trying in my world, it’s more like laying traps.
I have some questions about this incident, and I wonder whether anyone closer to the UK CAA can answer them.
In my (limited) experience of aerobatic competition, there has always been a “director” on the ground, in radio contact with the aircraft, who can issue a STOP command at any time. I believe the same was true, in theory, for the Shoreham show.
For instance, the director might issue a STOP command if he sees that an aircraft is too low/slow to enter the next manoeuvre in the sequence.
However, it seems to have been UK CAA policy that the display director should not be able to exercise such control, not least because the CAA rejected the AAIB’s Safety Reccomendation 2009-052 (arising from a previous display accident at Shoreham):
It is recommended that the UK Civil Aviation Authority requires that the sequence of manoeuvres for a flying display is clearly specifed in advance of the display and provided to the display organiser and that the sequence is practised prior to displaying to the public.
Which leads me to ask:
1. Who was responsible for air display regulation at the CAA between September 2007 and 2009?
2. How many of those air display inspectors/regulators were personally or financially involved in the air display business?
3. If not out of self-interest, why did they resist the AAIB’s 2009 Safety Recommendation?
That looks like a very cheap shot @Jacko.
Safety Recommendation 2009-052 is mentioned only in section 1.18.8 of the report on page 119 and the explanation is given on that page. So you can answer your question 3 for yourself.
However it is believed to be impractical to require that individual civilian display pilots specify a display sequence prior to the display and are then not allowed to vary it or modify it in any way later. Circumstances and weather conditions on the day of the display, such as time pressure in the display programme and wind strength, may make it safer to vary a display, for example by moving one or more manoeuvres from the approved sequence or by flying a flat display, rather than adhere strictly to the display originally specified.
It looks reasonable to me.
