Flight Safety Pty Ltd
January 2014
Safety Alert
News from Flight Safety Pty Ltd
In This Issue
Just Culture Threatened
ASRS Safety Database
A321 lands without clearance
Quick Links
Join Our Mailing List

We are beginning a new series of Aviation Safety Oversight Briefing Notes, that we have called "Safety Alert", in 2014. It will cover important issues taken from our perspective as External Aviation Safety Auditors and Consultants. We trust you will find them informative.


Colin Weir, Managing Director
Flight Safety Pty Ltd


It is with deep concern that Flight Safety has received notification that CASA intends implementing a self-serving, monomanic policy re changes to the globally, tried and tested 'Non-punitive/Just Culture' Aviation Safety Management System.


This core quality control function is the cornerstone of aviation safety globally and any attempt to rearrange this critical mechanism without global acceptance, including ICAO authorisation, will be seen as a maverick and amateurish step-back in time, akin to draconian censorship laws as evidenced in many third world countries.


The one single factor that allows external aviation safety auditing to achieve its goal, is the sacrosanct, formal Safety Management System. Within this system is the Non-punitive/Just Culture and Confidential Reporting processes that generate the unfettered report-back incentive that in turn allows corrective and preventative actions to develop.


The significance of this is evidenced within regulatory systems, example below -


  Working Paper


France's Civil Aviation Code (s. L 722-3) states that: "No administrative, disciplinary or professional sanction can be imposed on persons who have reported a civil aviation accident or incident or an event..., under the conditions stated in section L. 722-2, whether or not those persons were involved in the accident, incident or event, unless those persons were themselves guilty of a deliberate or repeated breach of the safety regulations." [Translation]


This document, identified below and accessible on the internet at - 



- encapsulates, in clearly defined terms, the global awareness and acceptance of a formalised 'Just Culture' Safety Management System.


Paragraph 3.2 from this document (below), further clarifies the concept.


"3.2 The key to a successful voluntary incident reporting system lies in the voluntary informants' confidence in the non-punitive consequences of their actions in providing information. Most Member States assure a non-punitive principle for voluntary incident reporting, but it is necessary to guarantee the principle systemically. In the case of States which manage the non-punitive principle through their administrative guidelines, a government authority should be made to make a written commitment that the Member States shall not utilize voluntary incident reporting as material with which to seek punishment; or the non-punitive principle should be enshrined in the domestic law of that Member State. The result will be that voluntary informants have confidence in their national non-punitive reporting system, in turn bolstering the voluntary incident reporting system of the respective Member State."


If there is substance in the suggestion that CASA's submission to ICAO's 38th General Assembly was to oppose this and in effect undermine the process, then this is embarrassing in the extreme.


The following extract from Air Safety Support International has relevance -


"Leadership is central to safety culture:

  • The highest standards you can expect from the people you lead or seek to influence are the lowest you exhibit yourself.
  • By ignoring low standards you are approving them - you are communicating the message that low standards are acceptable.
  • Leadership is the communication of the actions and standards you expect by words, deeds and silence."

 If everyone in a company is trained to do their job in a safe manner and proactively look for hazards, you will then be approaching a new level of safety that is behaviour driven.  All the elements of a safety culture must be actively encouraged and demonstrated by managers on a regular basis to encourage all staff to participate, if this level is to be achieved.


A pretty good SMS with 100% buy-in is infinitely better than a perfect system with 0% commitment.'



We believe the leadership concept as described, defines the Command & Control problem and extended into the broader Regulator hierarchical environment, clearly highlights the responsibility and obligation that an incumbent Accountable Manager/Commander-in-Chief has to have, in order to achieve the Highest Standard.


We therefore respectfully request that CASA reconsiders this option in the interests of aviation safety and effective accident prevention and we request a joint and ongoing liaison with the Industry in achieving this aim.   


Maintained and published by nasa.gov 
ASRS The ASRS is an important facet of the continuing effort by government, industry, and individuals to maintain and improve aviation safety. The ASRS collects voluntarily submitted aviation safety incident/situation reports from pilots, controllers, and others.

The ASRS acts on the information these reports contain. It identifies system deficiencies, and issues alerting messages to persons in a position to correct them. It educates through its newsletter CALLBACK, its journal ASRS Directline and through its research studies. Its database is a public repository which serves the FAA and NASA's needs and those of other organizations world-wide which are engaged in research and the promotion of safe flight.

The ASRS collects, analyzes, and responds to voluntarily submitted aviation safety incident reports in order to lessen the likelihood of aviation accidents.

Briefing Powerpoint

ASRS data are used to:
  • Identify deficiencies and discrepancies in the National Aviation System (NAS) so that these can be remedied by appropriate authorities.
  • Support policy formulation and planning for, and improvements to, the NAS.
  • Strengthen the foundation of aviation human factors safety research. This is particularly important since it is generally conceded that over two-thirds of all aviation accidents and incidents have their roots in human performance errors.

Download In-Depth Briefing Presentation (PDF) >> 


Visit the ASRS Database >>

A321 landed without clearance after an earlier wake vortex encounter distracted the flight crew. 

A321 Just one of many examples of the value of confidential reporting:

Date: September 2013
Location: JFK Airport

"[We] landed JFK without a clearance. Pilot not flying switched from Approach to Tower frequency and erred on frequency selected on comm. Pilot not flying called for landing clearance and did not receive a reply. Proceeded with usual callouts and completed a normal landing then realized the error. On arrival approximately 40 west of JFK we were following a heavy B747 and had been hit with moderate wake turbulence. We requested an offset from the unseen aircraft to continue.

On final we got a visual on the aircraft which was sequenced right in front of us. There was crew technical discussion regarding winds, wake turbulence, go-around, etc., from that aircraft that would constitute a distraction. Spacing and strong winds from the north made for a wake turbulence free approach. After clearing, we contacted Tower and were issued taxi instructions. Captain (pilot not flying) focused on possible wake turbulence from the heavy 747 to the exclusion of normal operations; missed the gorilla so to speak."

Search the ASRS database >>