Aviation Industry & the Application of the Due Diligence Process

In this episode of Risk! Engineers Talk Governance, due diligence engineers Richard Robinson and Gaye Francis discuss the application of the due diligence process to the aviation industry. 

Richard discusses his recent presentation to the Australian Aviation Wildlife Hazard Group where he used the expert witness view: What is it that could have been done and if it had been done, would it have stopped it going wrong? 

Key take-aways:

- Hazards and vulnerabilities in aviation, 
- Why R2A stays away from the term risk and adopts the military approach which is to say threat, 
- Preferred communication tools, and 
- The point of the due diligence process, which legislation requires, is demonstrating you were diligent and demonstrated you cared; that you did everything reasonably practicable you could in the circumstance.

Find out more about Richard and Gaye’s consulting work at https://www.r2a.com.au.  

Transcript

Megan (Producer) (00:00):

Welcome to Risk! Engineers Talk Governance. In this episode, due diligence engineers Richard Robinson and Gaye Francis discuss the aviation industry and the application of the due diligence process.

(00:15):

We hope you enjoy the episode if you do we'd love a rating. Also, if you'd subscribe on your favourite podcast platform. If you have any feedback or topic ideas, please get in touch. Email admin@r2a.com.au.

Gaye Francis (00:34):

Hi Richard, welcome to another podcast session.

Richard Robinson (00:37):

Morning Gaye. It's good to be back.

Gaye Francis (00:38):

It is good to be back. Today we're going to talk about one of our industry specific applications of our due diligence work that we do. And today we're going to talk about aviation and how it relates to the aviation industry. And it's really based on a presentation that you recently gave to the Australian Aviation Wildlife Hazard Group at Melbourne Zoo recently and how that went. So I'm guessing if you do an intro of what you did for that conference and then we can have a chat about some of the language that they use in the hazards that they experience.

Richard Robinson (01:17):

Just from those remarks you might gather from what Gaye just said, that we don't normally practice these (podcasts) in advance. But anyway. Basically I gave the standard expert witness view of how you go about managing these things and just explained that after it's all gone wrong and other people have died or serious injuries occurred, and you all wind up in court, the expert witnesses pop up and say: What is it that could have been done, if it had been done, would've stopped it going wrong. And obviously, after the event, when the fact is certain, that's not that hard a task, it's usually pretty obvious after the disaster, what could have been done if it had been done would've dealt with the matter. And this is just hammering the point that the court's testing as a retrospective design review, whether all reasonable controls are in place. It's not testing whether or not there was a standard or target level of risk achieved because after the event that has no meaning.

(02:08):

And I have to say the group, I think the group got that pretty fast. They understood that. And in fact because of who they are, they're talking about obviously aircraft damage and aircraft falling out of the sky. For example, somebody was going through all the stats about the number of bird strikes around the world and how much damage had been caused and how many people had died. And one of those Max 8 collisions of about 186 people died or something like that. One of the reasons why I thought it might've happened is that they thought the pitot tube, which tells the aircraft what speed it's doing had got damaged. And so it was giving the wrong information and the most likely reason for doing that was that it had been struck by something. Now they couldn't find that obviously in the crash site because that would've occurred before everything started going wrong. And if you obviously include that particular incident, that expands it further. There were a couple of other things which I hadn't realized, which obviously I thought about it briefly.

(03:00):

Australia, for example, has these wasps that like building mud homes in holes and one of the most likely places to build it is in the pitot tube. And so these airspeed indicators of aircraft can often be damaged just because the wasps are doing their thing. And it can happen quite fast. Wasps build these mud nests pretty damn fast. If the aircraft's sitting there for 24 hours, then you could have a mud nest then it quite easily. So there's a whole lot of things they have to check.

(03:26):

But the other thing which was interesting was that... you might've noticed they called the Australian Aviation Wildlife Hazard Group. It used to bird strike, but they said, well, and as you would've observed fairly unhappily,

Gaye Francis (03:38):

I will share that one of the handouts in the bag was different wildlife strikes around the world. For example, giraffes in Botswana, an alligator in the US. So a number of other animals were also experienced on the runway.

Richard Robinson (03:53):

Well, somebody had a problem, an overseas pilot had a problem in Australia with an emu and they referred to it as an Ostrich, which sort of slowed the Australians down just a bit. And the other problem they have too is a lot of time you can't actually identify the bird strike because there's not much left. I mean, one of the handouts they gave us was a sort of picture of a Boeing 747 with a bit of red on the front saying, what splat is that? Because it's important to know what kind of bird strike it is.

(04:22):

I mean you can recall we did that one at Brisbane airport I think it was. And the only reason why they knew they'd had a bird strike is because the runner on one of the jet engines had gone and they'd been badly damaged. And the reason why that was the case was because it was the ring off a homing pigeon, and that was a steel ring that had got caught in the runner. And they sort of said, what's a homing pigeon, a racing pigeon doing in our engine at Brisbane airport? And then they discovered that the local

Gaye Francis (04:50):

Pigeon club.

Richard Robinson (04:51):

Pigeon club ran racing pigeons and they used to let the pigeons off close to the airport and depending on what the weather was and what was going on, sometimes the pigeons as a flock went across the runway. Obviously the launch site was relocated for the pigeons once this became clear that that was the case, but that was only became the case because they discovered this pigeon ring that goes around the ankle. That was the only thing that was left.

Gaye Francis (05:15):

I think one of the other interesting things in your bag was this dangerous 10 species identification that was in there and sort of names 10 Australian bird species that represented in the ATSBATBS statistics. And I think it's really interesting groups. There seems to be two groups. There's sort of galahs and flying foxes and seagulls, but then there's also the white ibis and the buzzard and there seems to be two groups. There seems to be groups of birds that fly in big flocks. So the number of birds is one of the issues, but then they also put these additional birds in where the buzzards, the white ibis, because of their sheer size and the mass of them.

Richard Robinson (06:00):

They exceed what the engine can handle. I mean most people seem to know that now they fire chickens at test jet engines and all it does is provide more thrust to the engine most of the time. But birds, birds big enough. That's what actually happened in the US where they landed in the river, they flew into a flock of Canada geece and Canada geese are such a size that they will take out an engine and obviously if you have a flock, both engines can go down because one of your main precautions or controls is that each engine is capable of delivering all phases of flight. And as long as only one engine goes down, you're good. That's the second engine goes down, that gets problematic.

Gaye Francis (06:42):

Okay. So we spent a lot of time talking about the hazards or the vulnerabilities that they're exposed to.

Richard Robinson (06:48):

That was the other point. You see, they talked about this a fair bit, you might've noticed they said the Australian Aviation Wildlife Hazard. So they changed it from bird strike to wildlife because kangaroos have been struck and emus have been hit and things like that. So that was a fair thing. But they also changed the hazard and the way they were defining the terms, you see, one of the things they'd realized is that the term risk is so badly used and abused that nobody really knows what it means. And I just expanded on them because they'd understood this already, but I just expanded the presentation. I mean we've got five, but the three key ones are because we had an underwriter speak just before me who was explaining what whole losses and what had gone on in the world and what they underwrote. And the other thing was there were an awful lot of people from Southeast Asia there too. About 30% of the audience, about 140 people were from other countries. And they were particularly impressed with what the Australians were doing and how they're doing it, and particularly the ATSBs database and how they presented the information.

(07:47):

Anyway, this business of the risk, because I said look, the underwriter spoke about the risk as the thing in itself like the hull and the aviation and the aircraft is the risk. The technical people always talked about risk, likelihood and consequence, the simultaneous depreciation of both. But when you wound up in court when the fact is certain the likelihood side of the equation is now one, it's happened. And so the only risk you're talking about was the likelihood of that particular event occurring. And so the courts were just talking about likelihood. So unless you actually had this understanding

(08:17):

Now the way they were defining it, they were saying that the hazard was the problem of bird strike or animal interference at all. Then they had the threat, which was the creature being there at all. Then they called the risk, the conjunction of aircraft with whatever might be hit. And then they called the consequence, the outcome. Now we, as R2A, obviously stay away from the word risk altogether and just adopt the military intelligence approach, which is to say threat. We're happy with the hazard definition I think. But then you would have the threat, which is the potential bird strike or whatever animal strike. And then we would call that the vulnerability, that follows the military intelligence process.

Gaye Francis (08:56):

And that's the coincidence of the airplane being there at the same time as the wildlife.

Richard Robinson (09:00):

Correct.

Gaye Francis (09:01):

Yeah, that makes sense.

Richard Robinson (09:05):

How well that went down. I've yet to see.

Gaye Francis (09:08):

Have to see at the next presentation whether they've changed the name in their group or not. So they've identified the hazard. What are the controls that they can put in place?

Richard Robinson (09:20):

Well, we actually had done this at a previous presentation and I was basically explaining how we particularly prefer single line threat barrier diagrams because they're just the most communicative of a device. I mean, they were talking about bow ties, but you know how large complicated bow ties people get lost in the detail.

(09:38):

And the only technique that we've found that really works. Now I did explain it by sort of putting the James Reason swiss cheese model up because the aviation sector for reasons that are slightly obscure to me, really like that one and just sort of pointed out that it's a better alternative. And the main reason why is because when you wind up in court, I mean the legislation's clear and you remember we didn't start, for example, the hazard and risk analysis for the Western Sydney Airport until the Australian government's solicitor had actually signed off on that the way we wanted to do it, which was consistent with the provision of the WHS legislation was the right way to do it. Not using target levels of risk and safety such as New South Wales wanted to use.

(10:18):

Now the other way which I explained is that the quickest way to get to the question of what's reasonable in the circumstances was to put up a pros and cons table. And so I put that example up and the example I had on the threat barrier diagram I think was a bird scare, which means that you have basically a radar there, which is putting a laser on the birds or whatever creatures around. So if you show up and you're a kangaroo, suddenly get a green laser pointed at you or something, which sort of makes you, I dunno what this is, but this is not a good place to be.

Gaye Francis (10:49):

So you're removing the vulnerability.

Richard Robinson (10:51):

Correct.

Gaye Francis (10:52):

The intersection of the two.

Richard Robinson (10:53):

But obviously they have radar that can pick these things up. It's hard to pick up a single bird on a radar, although a flock apparently does show up.

Gaye Francis (11:00):

Right.

Richard Robinson (11:01):

And ordinarily you wouldn't expect a single bird to be able to take out a major commercial aircraft. At worst, they damage one engine. And as I pointed out earlier, we design aircraft so any single engine of a two engine aircraft can maintain all phases of flight. Even if you had to go round, it could be done.

Gaye Francis (11:20):

And I guess for this approach as well. So that was the application to wildlife and birds. But we've also used this approach in many other aerodrome or airspace, collision risk reviews that we've done.

Richard Robinson (11:32):

Well, that's basically what we did for Western Sydney Airport. It was basically a single line threat barrier diagram. It was interesting because I had a chat with the CASA (Civil Aviation Safety Authority) guy afterwards. Obviously DASA, that's the Defense Aviation Safety Authority, (and they) basically go about it the way we describe. But CASA, to some extent, has reverted to using target levels of risk and safety, which we have expressed to them several times in the past. And you will recall, we declined to keep doing work for them when they reverted back to that.

Gaye Francis (12:00):

So they're using the target level of risk and safety that something's acceptable or not. But I mean, we've done some recent jobs in the last couple of years in New Zealand, and we've definitely used the WHS approach.

Richard Robinson (12:12):

The WHSA in that jurisdiction, NZ.

Gaye Francis (12:16):

And that was the precautionary approach. And I think one of the interesting things when we were looking at the airspace one, and it was based on a model that we developed for Tapo many years ago, and it was really saying, well, there's only half a dozen or so controls that you can put in place to make airspace safe.

Richard Robinson (12:35):

Correct.

Gaye Francis (12:37):

And you're really saying what's reasonable in the circumstances? And when you break it down to that by flipping that question, the review process becomes so much more straightforward and less complex.

Richard Robinson (12:50):

Well, I think the other point was, which I don't think people quite understand. I mean, when something horrible happens, there's a tendency to say, well, whose fault was that? Right? I mean, that's been explained to us that the rules of the road for the shipping business is all about finding fault for who's going to pay for it, in effect for what the damage was.

(13:07):

But the point about the due diligence processes, which is what the legislation requires, it isn't that you can be right all the time. And we come across this situation where engineers in particular, something bad's happened and the engineers sort of saying, it's all my fault. I didn't get it right. And you sort of got to point out to 'em. That's not the way the system works. Your duty is to be diligent. You can't be right all the time. Now the world's a complicated place, and the courts understand that. The courts aren't saying that you have to be right all the time. What the courts are saying is that you need to be diligent and demonstrate do you care? That's an entirely different thing. And so when you're talking to one of these engineers or somebody who's got themselves in the situation based saying, well, had you done everything reasonably, you could in the circumstance, because if the answer is yes, then you have been diligent.

Gaye Francis (13:53):

And what else could have you done in the circumstance?

Richard Robinson (13:54):

What else could you have done? That was the same story we had with that CFA captain who sort of said, look, I know if I keep doing this job as a volunteer for the next 10 years, I'm going to lose someone. But what I need to be able to do is look the relatives the next to kin in the eye and say, look, it wouldn't have mattered if it was my son or daughter there. We'd done everything reasonable we could. There are dangers associated with what you do here, and sometimes bad things will still happen.

Gaye Francis (14:21):

So I think we might wrap it there. But what we hope we've shown you today is, and we're going to continue in this season to do a number of applications to the due diligence process. So the due diligence process is a governance process, and it is a process that can be applied to basically anything. And I hope today that we've shown you just how we apply it in the aviation sector. So thanks for joining us, Richard, and we'll see you next time.

Richard Robinson (14:45):

Thanks Gaye.