In the wake of the crash, investigators from the Australian Transport Safety Bureau (ATSB), the lead investigation agency, and Civil Aviation Safety Authority (CASA) will be trying to determine why the aircraft lost power and was unable to be flown to a safe landing.
As part of the aircraft’s type certification it is required to be able to maintain a minimum 5% climb gradient following the failure of the critical engine on take-off. This means it should have been able to at least climb over local obstacles, and circle around for a landing.
So a key question in the minds of investigators will be the reasons why this particular aircraft on this occasion wasn’t able to achieve this.
If the malfunction was related to only one engine, there has to have been some other factor degrading the aircraft’s single engine performance.
Maybe the engine that failed did not auto-feather, or could not be feathered by the pilot. This is where the prop blades on the failed engine are rotated to produce minimal drag, allowing the plane to perform better with only one engine operating.
If the failed engine didn’t feather correctly, it could have resulted in the windmilling propeller producing significant additional drag and seriously affecting aircraft controllability.
Or perhaps a much more insidious problem occurred causing full or significant partial power loss on both engines, presenting the pilot with an extreme emergency situation to manage. If that were the case, there would have to have been a common failure affecting both engines, such as a fuel quality, fuel starvation or an engine management issue.
The investigators will be clearly interested in the engines, propellers and fuel systems. They will also be exploring all the aircraft’s other systems, such as avionics, flight management computers, airframe and flight controls, looking for any evidence of malfunction or anomaly that could have contributed to the cause of the crash.
Investigators will also have a focus on all the possible human factors issues. The pilot’s response to the emergency will be examined and any factors, such as fatigue, illness or health issues that could have contributed will be explored.
The investigation will be conducted as a systematic and scientific process. Everything that could have contributed to the cause of the crash will be considered. Many will be discounted. Some will inevitably be proven.
The investigators findings will be solely based on the evidence from the wreckage, and from analysis of evidence external to the aircraft, such as maintenance documentation, air traffic control recordings, available film footage and, not least, the observations of the witnesses.
The investigation will be an arduous and exacting task given the apparent fragmentation of the aircraft and the post crash fire. However, I believe ATSB investigators are among the best in the world and I have no doubt they’ll reveal the causal sequences that led to this accident, so that any lessons can be learned and corrective actions implemented to prevent recurrences.
Aviation is the safest means of transport in no small part due to the work of air safety investigators who shed light on the causes of those accidents which do occur. This accident will continue that tradition, I’m certain.
It is often said that our approach to health and safety has gone mad. But the truth is that it needs to go scientific. Managing risk is ultimately linked to questions of engineering and economics. Can something be made safer? How much will that safety cost? Is it worth that cost?
Decisions under uncertainty can be explained using utility, a concept introduced by Swiss mathematician Daniel Bernoulli 300 years ago, to measure the amount of reward received by an individual. But the element of risk will still be there. And where there is risk, there is risk aversion.
Risk aversion itself is a complex phenomenon, as illustrated by psychologist John W. Atkinson’s 1950s experiment, in which five-year-old children played a game of throwing wooden hoops around pegs, with rewards based on successful throws and the varying distances the children chose to stand from the pegs.
The risk-confident stood a challenging but realistic distance away, but the risk averse children fell into two camps. Either they stood so close to the peg that success was almost guaranteed or, more perplexingly, positioned themselves so far away that failure was almost certain. Thus some risk averse children were choosing to increase, not decrease, their chance of failure.
So clearly high aversion to risk can induce some strange effects. These might be unsafe in the real world, as testified by author Robert Kelsey, who said that during his time as a City trader, “bad fear” in the financial world led to either “paralysis… or nonsensical leaps”. Utility theory predicts a similar effect, akin to panic, in a large organisation if the decision maker’s aversion to risk gets too high. At some point it is not possible to distinguish the benefits of implementing a protection system from those of doing nothing at all.
So when it comes to human lives, how much money should we spend on making them safe? Some people prefer not to think about the question, but those responsible for industrial safety or health services do not have that luxury. They have to ask themselves the question: what benefit is conferred when a safety measure “saves” a person’s life?
The answer is that the saved person is simply left to pursue their life as normal, so the actual benefit is the restoration of that person’s future existence. Since we cannot know how long any particular person is going to live, we do the next best thing and use measured historical averages, as published annually by the Office of National Statistics. The gain in life expectancy that the safety measure brings about can be weighed against the cost of that safety measure using the Judgement value, which mediates the balance using risk-aversion.
The Judgement (J) value is the ratio of the actual expenditure to the maximum reasonable expenditure. A J-value of two suggests that twice as much is being spent as is reasonably justified, while a J-value of 0.5 implies that safety spend could be doubled and still be acceptable. It is a ratio that throws some past safety decisions into sharp relief.
For example, a few years ago energy firm BNFL authorised a nuclear clean-up plant with a J-value of over 100, while at roughly the same time the medical quango NICE was asked to review the economic case for three breast cancer drugs found to have J-values of less than 0.05.
Risky business. Shutterstock
The Government of the time seemed happy to sanction spending on a plant that might just prevent a cancer, but wanted to think long and hard about helping many women actually suffering from the disease. A new and objective science of safety is clearly needed to provide the level playing field that has so far proved elusive.
Putting a price on life
Current safety methods are based on the “value of a prevented fatality” or VPF. It is the maximum amount of money considered reasonable to pay for a safety measure that will reduce by one the expected number of preventable premature deaths in a large population. In 2010, that value was calculated at £1.65m.
This figure simplistically applies equally to a 20-year-old and a 90-year-old, and is in widespread use in the road, rail, nuclear and chemical industries. Some (myself included) argue that the method used to reach this figure is fundamentally flawed.
In the modern industrial world, however, we are all exposed to dangers at work and at home, on the move and at rest. We need to feel safe, and this comes at a cost. The problems and confusions associated with current methods reinforce the urgent need to develop a new science of safety. Not to do so would be too much of a risk.
The Victorian Water Industry Association (VicWater) is the peak industry association for water businesses in Victoria. VicWater plays an important role in the Victorian water industry: influencing government policy, providing forums for industry discussions on priority issues, and disseminating news and information to stakeholders. A key function of VicWater is the ability to share information and learn from other water corporations; this includes the annual VicWater OHS Seminar where safety professionals from across the state get together for a 2-day conference to discuss all things safety. All Victorian water corporations were represented including members from Yarra Valley, City West and South East Water.
As part of this seminar, Safety Dimensions was invited to present a case study looking at the Safety Culture journey at Melbourne Water. Safety Dimensions has for the past 5 years, and continues to partner with Melbourne Water throughout their safety culture journey and we are certainly in a strong position to be able to speak on this topic. Safety Dimensions has extensive experience working with the Australian Water Industry and with organisations whose core services are supplied to the water industry. From major metropolitan water corporations such as Sydney Water and Melbourne Water, through to smaller Regional Water Corporations such as Gold Coast and Hunter Valley Water; we understand the unique challenges associated with working in this, often complex, and diverse work environment.
The aim of this session was to share valuable insights with the group on how Melbourne Water has proactively worked to change the safety culture within the organisation.
This included an overview of:
Where did Melbourne Water start and what were the challenges?
How did Melbourne Water address these challenges?
Types of programs used to address safety
Initial & ongoing culture surveys
Master class, executive alignment
Safety Leadership Foundation Program
The MATE’s program
What were the results and how have these results impacted on the business
Challenges along the way and key factors to success
Critical watershed moments with Senior Management – what worked? Influential leverage and how to step around the organisational quicksand, challenges in cultural change, tipping point etc.
The presentation was extremely well received with great discussion at the conclusion of the session. A common theme was ‘How to balance needs with budget’. Many of the Victorian Water Corporations do not necessarily have the same resources or budget as Melbourne Water and questioned the feasibility of implementing such broad scale Safety Culture Initiatives in their organisations. Safety Dimensions ability to design and deliver interventions on both the large and small scale, requiring varying levels of financial and time investment, clearly demonstrated to the attendees that Cultural Change Initiatives are achievable regardless of the size of the organisation and or budget.
This type of event can only yield positive results as it actively promotes open discussion and sharing of information, and as we all know, communication is a key ingredient in effective safety management. Safety Dimensions feel very humbled to be involved and we would like to thank VicWater for the opportunity to be involved.
If you would like to speak to one of our consultants who works extensively in the water industry – please call 1300 453 555.
It’s Men’s Health Week 9 -15 June!
If it’s time you, or a bloke in your life got something checked out – do it this week!
Supported by the Men’s Health Information and Resource Centre of UWS, the Department of Health and Beyond Blue, Men’s Health Week has a direct focus on the health impacts of men’s and boy’s environments.
According to the ABS, a boy born in Australia in 2010 has a life expectancy of 78.0 years while a baby girl born at the same time could expect to live to 82.3 years old. Right from the start, boys suffer more illness, more accidents and die earlier than their female counterparts.
Men take their own lives at four times the rate of women (that’s five men a day, on average) and accidents, cancer and heart disease all account for the majority of male deaths. Check out the statistics here.
Men’s Health Week serves to ask two questions:
What factors in men’s and boy’s environments contribute to the status of male health?
How can we turn that around and create positive environments in men’s and boy’s lives?
Men’s Health Week focuses on bringing together local services, groups and individuals to tackle the most important health issues relevant to local blokes. You decide what your health priorities are – this site will help you with ideas from health experts.