Sunday, January 29, 2017



NTSC (National Committee for Transportation Accident) Indonesia noted that the number of aircraft accidents has doubled in the past two years. The data released November 2016 said, in 2014 plane crash happened seven times, in 2015 the figure rose to 11 events and, in 2016 to 15 accidents. For the category of a serious incident, the NTSC recorded 23 occurrences of serious incidents in 2014, 17 events the following year, and in 2016, the figure rose to 26 events. Meanwhile, in 2016, there were at least six times air crash involving several aircraft and helicopters belonging to the military and police.
What's wrong with our aviation? What's wrong with military and police flights?

Technological and regulatory methods have been successful in reducing the civilian aircraft accident significantly until 1975. After 1975 the number of accidents, although low, can not be reduced again by both methods. Another method is needed in efforts to prevent a plane crash.
ICAO then decided to create a new method in addition to the two methods. The method used and, it is the ICAO policy to be implemented by ICAO member states, including Indonesia, is a method of incident analysis, contained in Doc 9422 Accident Prevention Manual. Each incident must be reported to be analyzed and then set preventive measures plane crash.
This policy is set by the paradigm that the plane crash was the accumulation of incidents. It is said that of the 600 incidents that have not been investigated, 30 minor accidents, 20 serious accidents and one fatal accident will happen. Each aircraft incident should be investigated with the aim not to blame someone but to be used as learning materials (lesson learned) in order to prevent recurrence of similar accidents again. Thus, the success of the prevention of air accidents is highly dependent on incident reporting.

Will offender honestly report and telling the truth about what happened in the accident or incident that has been done? It is human nature to cover up mistakes made by individuals, because of shame and pride especially when there is the threat of criminal penalties. Therefore, in the early stages of the incident reporting program it is voluntary and anonymous. Of course the number of voluntary reporting is very limited. Many incidents are hidden due to various reasons mentioned above.
To develop a reporting culture, the international aviation community and ICAO proposed the concept of just culture in which the doers of the incident are not punished unless there is a behavior that is an unacceptable. In one of the strategies in the ICAO Global Aviation Safety Plan, that is Effective Errors And Incident Reporting Systems, ICAO requested the State to amend the Aviation Act to incorporate the principles of just culture.
In Denmark, for example, incidents were reported just 15 incidents per year, but after the liability and protection against incident reports included in the Aviation Act, there were 980 reported incidents. Almost mid-air collision (near-miss) from 15 to 50 times per year. In Denmark's case shows how many incidents of flights that had been hidden, unreported and not investigated.

To make the doer willing to report any incident with complete data, it must be created conditions where the doer of the incident is not punishable. There should be a condition where honesty is encouraged and developed, where honesty is greatly appreciated, there is an atmosphere of trust (an atmosphere of trust in which people are encourage, even rewarded, for providing essential safety-related information). In Indonesia, the obligation to report any incidents and protection for whistleblowers has been regulated in the Aviation Act No.1/2009 in the article 321.
The problem now is whether all ranks from the operational level up to the top management understands and ready to behave according to the reporting culture? When the, operational level, pilots, mechanics, ATC and others are ready to provide a report of every incident as mandated by ICAO and Aviation Acts, is the director ready to receive reports of incidents? Is the investigation team ready to investigate and analyze using the appropriate investigative models, as recommended by ICAO, to find out the latent failures of the incident, i.e the wrong decisions made by the director, in addition to active failures related to operational personnel errors? Are we ready to report the findings about latent failures to the boss? Are we ready to report to the manager of the findings about latent failures? Is not there a worry that we will be dismissed by the top management when we submitted the report? Is the top management ready to behave by saying: I would like know the incidents rather than punish the offender? Will the top management would honestly accept all incident reports and then want to implement all the recommendations of an incident investigation related to latent failures? Will he make improvements of existing systems? Will he takes correction to the wrong decisions?
Honesty which is expected to grow and develop in flight operations personnel for reporting and telling the truth about what is happening in any accident or incident shall be accompanied by honesty of the top and middle management's to analyze deeply any incident and willing to accept gracefully the findings of latent failures and then want to correct mistakes in the system in accordance with the recommendations of the investigation.
In a aviation scientific reference, Indonesia is included in the group of countries that have high power distance cultures where there is a large distance between the junior and senior. Junior was very respectful of senior and afraid to provide input.
Junior respect for seniors and afraid to provide input. Seniors do not want to be criticized and often ignore the input of junior. Copilot will take such a long time to look for words that are polite to reprove Captain Pilot who made a mistake, even though both had been trained CRM (Cockpit Resource Management), which seeks to eliminate the high power distance.
When the culture of a high power distance still exists within operational staff and Indonesia Aviation Manager, civilian and military, the aircraft accident and incident investigation will not be effective as a method of prevention of aircraft accidents. Aircraft accidents will continue to happen.

Can aviation people in various layers act and behave honestly? Honest in reporting the incidents, honest in accepting the report and analyzing the incident, honest in accepting the recommendations of incident investigation and honestly implement improvements in accordance with those recommendations?
Cultural values contained in reporting culture is honesty. Aviation must be managed with honesty. Aviation is one of the industrial complex socio-technical system that requires accurate coordination and interaction of many professionals and diverse technology components which if not managed with honesty then that will happen is a major disaster (catastrophes).
Conclusion, if there are a lot of plane crash in a country, the hypothesis is that aviation (as well as sea and land transportation) in the country have not been managed honestly. This hypothesis would need to be proven through studies that also honest.
{The article was firstly written in Media Indonesia, June 18, 2009 and edited in January 2017 by: Dr. Drs. Yaddy Supriyadi SH MM SSiT, Vice Chairman, Air Law Society (Masyarakat Hukum Udara, MHU) Jakarta, Indonesia}


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