737H Doco and a darker side to it that you didn't know (or want to know)...

[gumpy]

At the moment we do know that the risk is limited to the risk of a plane running off the end of a runway. Even if these allegedly poorly construction aircraft fall apart 100% of the time when the aircraft goes bush. We still know that the risk of that happening is the same as the risk of the aircraft going bush. I know enough about risk to understand the Swiss cheese concept and to the focus on the limiting risk factors rather than the consequence.

I talk to people everyday who are concerned about dying from cancer (the consequence) and want thousands of dollars thrown at them. But forget the risk of that happening is the same as the risk of them having a car accident when driving 30 km.



That's a massive assumption that CASA has failed in their duties. Remember this is a world wide issue and Australia is not the odd one out by any stretch of the imagination.

Can I say that you don't seem to understand how responsibilities fall. The PM is head of our government but responsibilities are assigned to various ministers. The ministers can then devolve responsibility downwards, to say CASA. They then become responsible for ensuring that the delegated party have the capability and systems in place to discharge their responsibilities on behalf of the minister. The person at the top is only responsible of proving the next person down failed in their delegated duties and responsibilities. This applies to the PM or to Joyce.

You can talk about the ideal world as much as you wish but don't ignore the reality of governance systems.

1. The risks you have mentioned should then lead you on to the conclusion that more investigation needs to be done to properly understand what needs to be done. Limiting risk factors isn't even a term that's used and doesn't make sense.

You also haven't answered the question of when is this risk going to get worse and therefore affect more things than botched landings?

2. You have no idea how responsibilities fall and no idea how the corporate and government system works. All the ministers and agencies flow up the line. In the end one person is ultimately responsible. It's their duty the right people are in place to make the right decisions. If there is a break down the top person steps in and rectifies the situation. If an organisation fails it's on the leader's shoulder. You appear to be from the medical industry where the doctors passed down responsibility to others like nurses. It's a blame passing industry and it reflects in your response.

And yes it's an international issue but it's CASA's job to make sure Aussie's are safe. Just like other agencies make sure goods imported into Australia meet Aussie standards eg cars, electrical goods... basically everything that's imported. Again you have no idea,

 

[medhead]

1. The risks you have mentioned should then lead you on to the conclusion that more investigation needs to be done to properly understand what needs to be done. Limiting risk factors isn't even a term that's used and doesn't make sense.

You're right, I should have said the limiting risk factors. In the hypothetical situation of an aircraft running off the runway and then breaking apart because of poor construction. The limiting risk is the risk of running off the runway, even if the risk of it breaking apart is 1.

You also haven't answered the question of when is this risk going to get worse and therefore affect more things than botched landings?

I don't need to answer that, it is a question for Boeing and all the authorities around the world. That all happens behind closed doors. I'm confident that Boeing, qantas and other airlines will make whatever changes are warranted.

2. You have no idea how responsibilities fall and no idea how the corporate and government system works. All the ministers and agencies flow up the line. In the end one person is ultimately responsible. It's their duty the right people are in place to make the right decisions. If there is a break down the top person steps in and rectifies the situation. If an organisation fails it's on the leader's shoulder.

That's exactly what I'm saying. The leader puts in the right person. If there is a break down it is too late to step in as something has already gone wrong. The leader then says "I had the right person making the right decisions. I did what I needed to do to make it work". The spotlight then turns to the right person and they have to explain.

Take a minor example, the new VA SC earning corrections. Are you seriously suggesting that Borghetti has his hands up saying "yep I stuffed up, I'm the leader, shoot me". Or do you think he has sent an email to the velocity manager (the right person, making the right decisions) to say WTF!"

And yes it's an international issue but it's CASA's job to make sure Aussie's are safe. Just like other agencies make sure goods imported into Australia meet Aussie standards eg cars, electrical goods... basically everything that's imported. Again you have no idea,

you might be surprised about what I know after working for a long time, in a fairly senior role in one of those agencies that protect the Australian public.

Also don't get confused by my nickname, I've had it since high school. Edit: but it was nice to read your post after getting back from doing the exact opposite of what you suggested, with a big of feeling and all.

 

[gumpy]

You're right, I should have said the limiting risk factors. In the hypothetical situation of an aircraft running off the runway and then breaking apart because of poor construction. The limiting risk is the risk of running off the runway, even if the risk of it breaking apart is 1.



I don't need to answer that, it is a question for Boeing and all the authorities around the world. That all happens behind closed doors. I'm confident that Boeing, qantas and other airlines will make whatever changes are warranted.



That's exactly what I'm saying. The leader puts in the right person. If there is a break down it is too late to step in as something has already gone wrong. The leader then says "I had the right person making the right decisions. I did what I needed to do to make it work". The spotlight then turns to the right person and they have to explain.

Take a minor example, the new VA SC earning corrections. Are you seriously suggesting that Borghetti has his hands up saying "yep I stuffed up, I'm the leader, shoot me". Or do you think he has sent an email to the velocity manager (the right person, making the right decisions) to say WTF!"



you might be surprised about what I know after working for a long time, in a fairly senior role in one of those agencies that protect the Australian public.

Also don't get confused by my nickname, I've had it since high school.

1. You still haven't full explored and understood the risk. It's still an unknown and until you investigate it properly we don't know how bad it is. The plane is not acting it the way it should be when they're stuffing up the landing... this should be a trigger of "we should find out what's wrong" not "oh we better just not stuff up landings." If people all thought like you, the world would be in a very bad state.

2. You do need to answer the question because the Doco reveals a culture of cover ups. Your response to this is very naive. "Lets all assume all the companies and acting in our best interests." Just like Ford did with the Explorer, just like the tabacco companies, just likethe US beef industry that feed grains and antibiotics to the cows instead of grass... :shock:

3. Like on other threads you have poor analogies - a velocity points stuff up is a minor issue, like a tax refund that's off by say 20 bucks, again minor issue. Say for some reason, hypothetically, the velocity points stuff up was so consistent and bad that all the FF's left and ruined VA. Would that fall on the CEO's shoulder? Hell yes. Am I saying this will happen no, but when it is a major error it goes all the way to the top. If 737's start falling part mid flight killing people would this fall on the PM's should when it was brought to the attention of her office? Hell yes.

 

[mannej]

Just a minor point, you state refer to the documentary. Is there any other information available? Yes it could be considered compelling evidence, however one thing that sticks with me is the fact that they labelled TK1951 as a runway overrun.
TK1951 was quite clearly not a runway overrun, so with that small piece of misinformation, how much more of the information that is presented has been checked?
One interesting thing that has not been mentioned are the motives of the whistleblowers. Did either of you know that if they were found to be correct, they would be entitled to monetary damages. Is that their motive for the claims, dressed up as a safety issue?

I am not saying either way, but I feel that the documentary asks more questions that what it answers.

 

[medhead]

Apologies in advance if this is brief and I miss stuff. I've tried to do this 3 times on iphone and people keep ringing :evil:

1. You still haven't full explored and understood the risk. It's still an unknown and until you investigate it properly we don't know how bad it is. The plane is not acting it the way it should be when they're stuffing up the landing... this should be a trigger of "we should find out what's wrong" not "oh we better just not stuff up landings." If people all thought like you, the world would be in a very bad state.

This is about the swiss cheese model - multiple controls. Hypothetically, if the aircraft falls apart everytime the landing is stuffed up. I still know the risk of stuffing up the landing and that I can control the likelihood of the aircraft falling apart by not stuffing up the landing. (actually, just realised I was confusing risk with likelihood ) So there is not an urgent need for the PM to set up a royal commission into aircraft manufacturing in the USA.

2. You do need to answer the question because the Doco reveals a culture of cover ups. Your response to this is very naive. "Lets all assume all the companies and acting in our best interests." Just like Ford did with the Explorer, just like the tabacco companies, just likethe US beef industry that feed grains and antibiotics to the cows instead of grass...

The car industry is hardly a good indicator of aviation. The consequence side of risk in the car industry is so low that no one cares. There is also the 707 cargo door incidents that supposedly lead to total changes in how the FAA operates.

3. Like on other threads you have poor analogies - a velocity points stuff up is a minor issue, like a tax refund that's off by say 20 bucks, again minor issue. Say for some reason, hypothetically, the velocity points stuff up was so consistent and bad that all the FF's left and ruined VA. Would that fall on the CEO's shoulder? Hell yes. Am I saying this will happen no, but when it is a major error it goes all the way to the top. If 737's start falling part mid flight killing people would this fall on the PM's should when it was brought to the attention of her office? Hell yes.

It is actually a good analogy, as it is designed to illustrate how responsibilities are delegated and devolve, rather than explore details. How a company deals with minor issues is illustrative of how they will deal with major issues.

However, if we look at the details of your hypothetical, you are not talking about a situation where the right person is making the right decisions. If there are consistent problems as per this situation, then either the CEO is not doing their job or they have the wrong person in there or both as the CEO mustn't be supervising properly. so in that situation yes, it falls at the top. But there is no way for you to say there is a consistent problem in government over this single issue. A one off occurrence is not going to prevent the top person from being able to prove they have proper oversight. You sent an email to the PM, if something happened where that became relevant, the PM is just going to say "I sent the email to CASA, the experts and responsible agency. CASA provided this advice back to me. I have this governance system set up so I have discharged my supervisory role. I have given CASA this much funding to carry out their role. This is a one off and CASA stuffed up."

 

[gumpy]

Apologies in advance if this is brief and I miss stuff. I've tried to do this 3 times on iphone and people keep ringing :evil:



This is about the swiss cheese model - multiple controls. Hypothetically, if the aircraft falls apart everytime the landing is stuffed up. I still know the risk of stuffing up the landing and that I can control the likelihood of the aircraft falling apart by not stuffing up the landing. (actually, just realised I was confusing risk with likelihood ) So there is not an urgent need for the PM to set up a royal commission into aircraft manufacturing in the USA.



The car industry is hardly a good indicator of aviation. The consequence side of risk in the car industry is so low that no one cares. There is also the 707 cargo door incidents that supposedly lead to total changes in how the FAA operates.



It is actually a good analogy, as it is designed to illustrate how responsibilities are delegated and devolve, rather than explore details. How a company deals with minor issues is illustrative of how they will deal with major issues.

However, if we look at the details of your hypothetical, you are not talking about a situation where the right person is making the right decisions. If there are consistent problems as per this situation, then either the CEO is not doing their job or they have the wrong person in there or both as the CEO mustn't be supervising properly. so in that situation yes, it falls at the top. But there is no way for you to say there is a consistent problem in government over this single issue. A one off occurrence is not going to prevent the top person from being able to prove they have proper oversight. You sent an email to the PM, if something happened where that became relevant, the PM is just going to say "I sent the email to CASA, the experts and responsible agency. CASA provided this advice back to me. I have this governance system set up so I have discharged my supervisory role. I have given CASA this much funding to carry out their role. This is a one off and CASA stuffed up."

1. Not asking for a royal commission (you have a tendancy to bring out the best or worse case senario depending on how it suits your arguement), not asking for people to fly over to Boeing and go through all their documents. Asking for the regulator to order a special review of all planes affect fly in Australia so that they know if there is an issue, if there is an issue how big the issue is and how the issue can be managed going forward so that there is no increased risk because of manufacturing shortcuts.

2. Yes the aviation consequences are worse and from the information we have they're covering it up just like the car industry. Also the food industry the consequences are worse than the aviation industry, the same thing though... where there are profits involved the decisions are not always in the best interest of the consumer and public.

3. Your arguement stands IF CASA did a proper investigation, have all the documentation and have reported back no issue (AND I STRESS THIS IS ALL I WANT TO HAPPEN). If CASA don't follow up on the concerns and report back or the investigation is inadequate then it's on the PM's head.

 

[gumpy]

Just a minor point, you state refer to the documentary. Is there any other information available? Yes it could be considered compelling evidence, however one thing that sticks with me is the fact that they labelled TK1951 as a runway overrun.
TK1951 was quite clearly not a runway overrun, so with that small piece of misinformation, how much more of the information that is presented has been checked?
One interesting thing that has not been mentioned are the motives of the whistleblowers. Did either of you know that if they were found to be correct, they would be entitled to monetary damages. Is that their motive for the claims, dressed up as a safety issue?

I am not saying either way, but I feel that the documentary asks more questions that what it answers.

1. I understand your point and this is why I'm saying we need inspections of the planes. Not saying scrap every 737-800 from this manufacturing period.

2. In the world of audit and risk whistleblowers are key to uncovering 80% of all frauds. To even get 1 whistleblower is a very good start let alone two with pictures and other evidence supporting their case. Remember Erron's demise started with one lady pointing out it was all BS...

Never-the-less there are times where the whistleblower is a disgruntled employee but the correct procedure is to investigate and come to an objective conclusion, not to wash over it because if their accusations are true then the public may be in danger.

 

[medhead]

1. Not asking for a royal commission (you have a tendancy to bring out the best or worse case senario depending on how it suits your arguement), not asking for people to fly over to Boeing and go through all their documents. Asking for the regulator to order a special review of all planes affect fly in Australia so that they know if there is an issue, if there is an issue how big the issue is and how the issue can be managed going forward so that there is no increased risk because of manufacturing shortcuts.

2. Yes the aviation consequences are worse and from the information we have they're covering it up just like the car industry. Also the food industry the consequences are worse than the aviation industry, the same thing though... where there are profits involved the decisions are not always in the best interest of the consumer and public.

3. Your arguement stands IF CASA did a proper investigation, have all the documentation and have reported back no issue (AND I STRESS THIS IS ALL I WANT TO HAPPEN). If CASA don't follow up on the concerns and report back or the investigation is inadequate then it's on the PM's head.

I was only pitching at Royal Commission to match the level that you targeted with the email, i.e. the PM. A bit flippant, but I still applaud you for taking the time to write.

I think the higher consequences the more carefully the industry. I've seen this in my work and I would also cite nuclear power as a prime example. 3 accidents, one was catastrophic and no more than a few 100 deaths. Compared to coal power this is a great record, the smog in london in the 1950s or 60s killed thousands alone. Yes, this is hand waving stuff to some extent, but I'm well off topic now.

In relation to 3, it only fails if there is a pattern of poor performance and the PM is aware of it. In a one off failure to investigate, if the agency writes back and says all is well, there is no cause to doubt that answer. I've kept this more general, because it can apply to just about any organisation and it is one of the underlying principles of our system of government. Anyway, I'll leave it at that because I could rant on for hours on this topic and it wouldn't all be positive.

 

[2353]

1. I understand your point and this is why I'm saying we need inspections of the planes. Not saying scrap every 737-800 from this manufacturing period.

2. In the world of audit and risk whistleblowers are key to uncovering 80% of all frauds. To even get 1 whistleblower is a very good start let alone two with pictures and other evidence supporting their case. Remember Erron's demise started with one lady pointing out it was all BS...

Never-the-less there are times where the whistleblower is a disgruntled employee but the correct procedure is to investigate and come to an objective conclusion, not to wash over it because if their accusations are true then the public may be in danger.

I would have thought if the FAA (as they have the jurisdiction over an US based aircraft manufacturer) finds evidence to support the doco, they will make inspections of a number of the "suspect" planes - it is not in their interests to sweep a claim like this under the carpet. Assuming (for a minute) the claims are absolutely true the FAA (and consequently CASA and a number of other authorities) will also direct their individual 737 owners to make the same inspections. Will this make media headlines - probably not as they will have moved on to the next gloom and doom "we're all going to die" scenario.

In other words - at some point you've got to trust the system. It's not the Australian Government's fault, the PM is not personally responsible for (and probably doesn't even know about - in the way JB probably wouldn't know how to operate a Virgin Australia check in desk) the daily workings of the system, QF & VA will in all probability be inspecting anything they think may be a problem assuming there is sufficient detail available to make an informed decision.

IF you want the Government to "save" you from all risks - are you prepared to argue for tax rises to ensure the Government has the resources to do so?

 

[gumpy]

I would have thought if the FAA (as they have the jurisdiction over an US based aircraft manufacturer) finds evidence to support the doco, they will make inspections of a number of the "suspect" planes - it is not in their interests to sweep a claim like this under the carpet. Assuming (for a minute) the claims are absolutely true the FAA (and consequently CASA and a number of other authorities) will also direct their individual 737 owners to make the same inspections. Will this make media headlines - probably not as they will have moved on to the next gloom and doom "we're all going to die" scenario.

In other words - at some point you've got to trust the system. It's not the Australian Government's fault, the PM is not personally responsible for (and probably doesn't even know about - in the way JB probably wouldn't know how to operate a Virgin Australia check in desk) the daily workings of the system, QF & VA will in all probability be inspecting anything they think may be a problem assuming there is sufficient detail available to make an informed decision.

IF you want the Government to "save" you from all risks - are you prepared to argue for tax rises to ensure the Government has the resources to do so?

Firstly did you watch the doco? Many of your points are addressed in it.

In some instances it is in their interest to sweep it under the carpet. The US system in certain areas is really messed up, ie food. I didn't know the FAA let Boeing self regulate... like seriously...

2ndly, if CASA did any sort of investigation VA and QF's response to the questions would have been, CASA gave us the all clear, we do checks as normal, there is no issue. However, they did not refer to any CASA involvement at all.

Finally, I'm not saying they need to know all the workings and that the doco is conclusive proof of anything. What i'm saying is there are two whistleblowers so someone should investigate these claims. If they do a proper investigation and find there is no issue, fantastic... but no one has done this yet??? So I bought it to the attention of the PM's office, hopefully it filters through and someone from CASA checks it out. I know this is unlikely to happen bit I hope it does.

 

[gumpy]

I was only pitching at Royal Commission to match the level that you targeted with the email, i.e. the PM. A bit flippant, but I still applaud you for taking the time to write.

I think the higher consequences the more carefully the industry. I've seen this in my work and I would also cite nuclear power as a prime example. 3 accidents, one was catastrophic and no more than a few 100 deaths. Compared to coal power this is a great record, the smog in london in the 1950s or 60s killed thousands alone. Yes, this is hand waving stuff to some extent, but I'm well off topic now.

In relation to 3, it only fails if there is a pattern of poor performance and the PM is aware of it. In a one off failure to investigate, if the agency writes back and says all is well, there is no cause to doubt that answer. I've kept this more general, because it can apply to just about any organisation and it is one of the underlying principles of our system of government. Anyway, I'll leave it at that because I could rant on for hours on this topic and it wouldn't all be positive.

Look all I want is CASA saying it's all good, or saying these 3 planes need to me decommissioned, or we need to reaccess in 5 years time because there are defects but it's not that bad... etc... or the whistleblowers BS artists, just something public with good levels of documentation and investigation.

As for 3, one big error by key personnel and it still flows up the chain. Only time it wouldn't is if there was no error ie: 1. the correct person was in the job. 2. They did the best investigation possible (ascertained by peer review). 3. They just did not find it. Ie they weren't negligent in the discharge of their duties.

Finally bleh... i'm going to do my best to stay off these planes, I hope there are no accidents, I hope it's resolved, to everyone who's flying in them (including me) good luck...

 

[medhead]

Ie they weren't negligent in the discharge of their duties.

this is the key point, if anyone, from the top down, can show they weren't negligent then they can avoid blame.

 

[Happy Trails]

Another one bites the dust:

Caribbean Airlines crash in Guyana: 163 escape plane that snapped in 2 | Mail Online

 

[gumpy]

Another one bites the dust:

Caribbean Airlines crash in Guyana: 163 escape plane that snapped in 2 | Mail Online

yep, it snapped and killed people again... all evidence points to the fact that there is some true behind that doco... They really should investigate it properly and publicly announce it's ok or a problem.

 

[UP4014]

gumpy with the rumors around Airbus and pitot tubes and computers set up allow less skilled crew to fly planes, can you let us know if your happy to fly on an Airbus?

The news report around this latest crash actually says no one was killed and if you look at the terrain the aircraft is sitting in I'd say I'm surprised it is only in 2 bits after bumping over that small ridge.

Matt

 

[gumpy]

gumpy with the rumors around Airbus and pitot tubes and computers set up allow less skilled crew to fly planes, can you let us know if your happy to fly on an Airbus?

The news report around this latest crash actually says no one was killed and if you look at the terrain the aircraft is sitting in I'd say I'm surprised it is only in 2 bits after bumping over that small ridge.

Matt

For the first question yes because I select airlines who I believe have well trained pilots. As much as QF piss me off some times when in doubt I'm back on a QF flight. Unlike the 738 situation there's no defect with the plane.

For the 2nd point, yeah I may have jumped the gun on the people dying but the thing is it shouldn't have broken per then engineer in that doco... and also like the doco it's broken in the same spot under the same circumstances.

 

[samh004]

First thing I thought of when I saw that plane on the news was this thread, however it didn't break into three, though it has broken at the same point by the looks of things. Will be interesting going forward from here I reckon. Luckily the point where it breaks looks to be safe for most people.

I'd sell the car or get it fixed. I might take risks with myself but I wouldn't be able to live with it if my family got hurt because I pushed on knowing the defect was there.

It's the family car, not mine. It'll be fixed soon.

 

[mannej]

Gumpy, again jumping the gun. Out of all these over runs and the Turkish flight, I would think you find the majority of people have actually survived these accidents. The most who have died would be 9 from the TK accident?

 

[gumpy]

Gumpy, again jumping the gun. Out of all these over runs and the Turkish flight, I would think you find the majority of people have actually survived these accidents. The most who have died would be 9 from the TK accident?

The bigger picture is the issue Mannej. Whistleblowers have pointed out there is an issue, the way the planes have broken up indicate there might be some truth behind their claims. At the moment the issue only occurs when the planes don't land properly but when will the problem change to a failure whilst in the air? You have to step back and look at the bigger picture.

Anyway 9 people dying from a known defect is too many... I certainly wouldn't want anyone I know to be caught out by this...

 

[mannej]

The bigger picture is the issue Mannej. Whistleblowers have pointed out there is an issue, the way the planes have broken up indicate there might be some truth behind their claims. At the moment the issue only occurs when the planes don't land properly but when will the problem change to a failure whilst in the air? You have to step back and look at the bigger picture.

Anyway 9 people dying from a known defect is too many... I certainly wouldn't want anyone I know to be caught out by this...

I am still skeptical as to whether is it a known defect just based on the documentary. One thing that documentary also stated is the fact that the whistleblowers are entitled to compensation if their action succeeds. Are they in it for the "safety" or for the money?