On Air Safety and blame…

I was fascinated by this article that explains one reason the global air travel system is so safe. Many countries have been able to steadily improve safety because they don’t try to hold anyone at fault for incidents anymore.

Put another way: we’ve decided that when so many lives are at stake, it’s much more valuable to find out exactly what happened than it is to hold anyone to blame for an accident.

The central narrative is the heartbreaking story of an air traffic controller who made a genuine mistake which killed 35 people. Because the system wasn’t trying to find fault and punish anyone, she was willing to reveal everything that happened – all the missteps that led to to the accident – in an attempt to identify indirect causes and make the system safer.

Conversely, if someone is confronted with the possibility of going to jail, they’ll stop talking and lawyer up. The article mentions a Canadian incident that happened before this policy. To this day, it’s not known exactly what happened. The pilot continues to maintain a narrative that lessens his responsibility, but that others have called into question. Is he telling the truth? No one is sure, because he had a clear incentive to mislead at the time.

If we acknowledge that some mistakes are honest ones – and often, there are indirect causes that contribute to these mistakes – then the key people involved are likely to cooperate and reveal valuable details that can help us improve.

It’s counter-intuitive – no accountability leading to better results. But air travel is a very specific enterprise where small improvements can save a lot of lives, and that’s far more valuable that pursuing justice or retribution against specific people.