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> [Aviation] professionals are given every reason to cooperate, because they know that investigations are not about finding scapegoats, but learning lessons. In

by paol 11y ago

> [Aviation] professionals are given every reason to cooperate, because they know that investigations are not about finding scapegoats, but learning lessons. Indeed, professionals are given a legal safe space so they speak up honestly(...) This is probably the single most important thing that aviation got right and I don't think people understand that well enough, in general. The attitude in the air industry, when something goes wrong, is 1) understand what happened; 2) figure out what needs to be changed so it doesn't happen again. There is no step 3. There especially isn't a step of "punish those responsible" or some such nonsense. Only the final goal of improving outcomes matters, and indulging the emotional human demand for punishment does not necessarily help that goal, it can even seriously hinder it. If only we could apply the same rationality to, say, the penal system.

ksdale 11y ago
I agree completely that we tend to focus too much on punishment rather than preventing future harm. That said, one thing that makes the airline industry unique is the binary nature of problems. If something goes wrong and the plane doesn't crash, then there's no harm to passengers so it's easier to forgo punishment. If something goes wrong and the plane crashes, there's no one left alive to punish. Add to that the fact that there is no possible nefarious reason for a pilot to accidentally crash a plane. A pilot can crash a plane on purpose, but if they do something stupid and the plane doesn't crash, they're likely to be believed when they say it was just a stupid mistake. Compare to a doctor who doesn't suffer when a patient suffers (at least not physically) and in fact may even save money from certain oversights. It's much easier to assume bad intent where mistakes are profitable rather than fatal.
- wnevets 11y ago
  Pilots aren't the only ones who can make a deadly mistake in aviation. If a traffic controller or maintenance personnel makes a mistake, are they punished?
  - Retric 11y ago
    Sometimes, it depends on who notices the mistake and why. Consider, a safety first culture can easily penalize someone for showing up to work drunk IF someone notices before a problem shows up. But, if nobody notices till after the fact then they should be free to admit it without problems. Because there where two issues, they where drunk AND nobody noticed. You can't fix the second issue if you don't know it's a problem.
  - sokoloff 11y ago
    Absolutely, especially in the case of ATC. Now, the punishment is often "merely" decertification to work their position and re-training (with pay) until they're fully certified to work their position again, but it's still a pretty big deal to the ATCers I know. Maintenance personnel can also have their certificates suspended, though that tends to be more rare than being sued. (ATC is prevented from being sued in almost all circumstances, so that doesn't apply to them.) You can be sure that most fatal crashes result in at least an investigation of logbooks, who signed off the aircraft and for what, and some utterly absurd civil cases, many of which are settled without regard to the facts of the case but based on the perceived depth of pocket of the defendant.
- paol 11y ago
  You're right that there's a natural alignment of incentives between pilots and their passengers, but as wnevets points out above there are other critical participants in the system that aren't travelling in the plane. Your "binary nature of problems" comment is wrong though. First common misconception: statistically the most probable outcome for someone involved in an airplane crash is survival, not death [0]. Second misconception: investigations routinely happen for incidents not resulting in crashes. In fact the whole point of promoting self-reporting of incidents by pilots is so that such investigations can be conducted for incidents that would otherwise never be known. [0] https://app.ntsb.gov/doclib/safetystudies/SR0101.pdf https://app.ntsb.gov/doclib/safetystudies/SR0101.pdf
  - ksdale 11y ago
    That's a very excellent point about other critical participants. I appreciate the additional information! I didn't mean to sound like I thought that people die all the time in airplane crashes, merely that the median mistake is way less likely to affect a passenger, which is a major criteria for deciding to punish in other professions. Every mistake a lawyer or doctor makes can hurt clients or patients, respectively, whereas for most mistakes a pilot makes, no one will even know they made it (except if they self report, which they do a lot as you pointed out). And then I added in the ill-advised part about dying, by which I was really trying to communicate that the really bad outcomes are so bad that punishment is the last thing on people's minds.
    - paol 11y ago
      > punishment is the last thing on people's minds I wish. Just off the top of my head, there was the swiss air traffic controller who was murdered by some relative of one of the victims of a mid-air collision [0], and the Brazilian government trying to put the surviving crew of another mid-air collision on trial [1]. Someone with better memory could surely think of more examples. [0] https://en.wikipedia.org/wiki/%C3%9Cberlingen_mid-air_collision https://en.wikipedia.org/wiki/%C3%9Cberlingen_mid-air_collis... [1] https://en.wikipedia.org/wiki/Gol_Transportes_A%C3%A9reos_Flight_1907 https://en.wikipedia.org/wiki/Gol_Transportes_A%C3%A9reos_Fl...
- Eric_WVGG 11y ago
  not exactly an aviation example, but applicable: the space shuttle Challenger tragedy was not caused by pilot error.
  - 0xdeadbeefbabe 11y ago
    Yes and Columbia.
- deleted 11y ago
  [deleted]
zardo 11y ago
We (try to) have a similar attitude about mistakes at our manufacturing facility. Even if the problem is employee did not follow instructions, the real problem is that the instructions were complicated, or they were only given once, or we don't have a check in place to verify the instruction was followed. Blaming people doesn't fix things.
- nkrisc 11y ago
  That's a great example. The goal is to modify behavior, and to do so you need to understand the conditions that lead to the undesirable behavior and change those conditions. Barring outright intentional malice, there's usually a good reason someone did (or did not do) something.
  - ThrustVectoring 11y ago
    I'd phrase it as "to modify future behavior", to emphasize that absolutely nothing you do can change what happened.
    - nkrisc 11y ago
      Yes, exactly! I think that's sort of the key thing about the aviation approach. You can't change what happened so there's not much point in blaming people. Assigning blame and punishment is one way of attempting to modify future behavior, though not always effective.
maxcan 11y ago
This is very true. The FAA really takes this seriously. So much so that since one of their duties is enforcement and potentially revoking licenses for violations they have built a system where NASA, a completely separate agency, manages the Aviation Safety and Reporting System (ASRS). When we, as pilots, submit ASRS reports of mistakes or dangerous situations we know that the information we submit on those reports cannot and will not be used against us in a FAA violation proceeding. Furthermore, submission of an ASRS report will often reduce or eliminate any penalties for an infraction. This has created a cover-your-ass-culture that actually promotes safety as we will often report mistakes and dangerous situations early and aggressively, knowing that we are protected from FAA action and for commercial pilots, from airline disciplinary processes.
- petra 11y ago
  This system is working great. But what about bad pilots ? How are they dealt with ?
  - curun1r 11y ago
    I'm not a pilot, but I'd imagine that it's a combination of recognizing and learning from each mistake and a ruthless punishment of severe mistakes. If you have a culture of reporting each and every mistake, you can receive feedback on what you could have done better in each and every one of those situations. That leads to bad pilots constantly becoming better pilots. Additionally, unlike the doctors in the story, severe mistakes in aviation will result in the death of the pilot, so like those startups that always fire the bottom percentage of their workforce, the really bad pilots will naturally eliminate themselves. Rockclimbing is similar to flying in their compulsion to study fatal accidents. Climbing magazines will publish fairly in-depth discussions, not out of morbid curiosity but, instead, as a campaign to build awareness among climbers of mistakes that can kill them. This has led to safer gear and practices used in the sport and has undoubtedly saved lives.
  - avn2109 11y ago
    By definition, the bad pilots have or will soon crash their aircraft, removing either themselves or at least their equipment (and unfortunately maybe their passengers) from circulation. I say this as myself a bad pilot, but one who is aware enough of that fact to always fly with dual control.
js8 11y ago
> Only the final goal of improving outcomes matters, and indulging the emotional human demand for punishment does not necessarily help that goal, it can even seriously hinder it. If only we could apply the same rationality to, say, the penal system. I completely agree. Humanity still has to grow up, to realize that helping other people is lot more efficient than punishment. I like the quote: "Emphasis on punishment is the sign of an obedience frame."
CaptSpify 11y ago
One thing I've learned in my career: Whenever there is a failure, it's almost always caused by more than one mistake. The root-cause could be someone not paying attention, but if that mistake can be disastrous, you shouldn't be relying on that one-point of failure. If "finding someone to blame" is the solution to a problem, your org has failed in more ways than one. I've had mixed experiences, but I find the orgs that set up roadblocks to prevent single-mistakes from causing issues are much better off.

by paol 11y ago

ksdale 11y ago

I agree completely that we tend to focus too much on punishment rather than preventing future harm. That said, one thing that makes the airline industry unique is the binary nature of problems. If something goes wrong and the plane doesn't crash, then there's no harm to passengers so it's easier to forgo punishment. If something goes wrong and the plane crashes, there's no one left alive to punish. Add to that the fact that there is no possible nefarious reason for a pilot to accidentally crash a plane. A pilot can crash a plane on purpose, but if they do something stupid and the plane doesn't crash, they're likely to be believed when they say it was just a stupid mistake. Compare to a doctor who doesn't suffer when a patient suffers (at least not physically) and in fact may even save money from certain oversights. It's much easier to assume bad intent where mistakes are profitable rather than fatal.

wnevets 11y ago
Pilots aren't the only ones who can make a deadly mistake in aviation. If a traffic controller or maintenance personnel makes a mistake, are they punished?
- Retric 11y ago
  Sometimes, it depends on who notices the mistake and why. Consider, a safety first culture can easily penalize someone for showing up to work drunk IF someone notices before a problem shows up. But, if nobody notices till after the fact then they should be free to admit it without problems. Because there where two issues, they where drunk AND nobody noticed. You can't fix the second issue if you don't know it's a problem.
- sokoloff 11y ago
  Absolutely, especially in the case of ATC. Now, the punishment is often "merely" decertification to work their position and re-training (with pay) until they're fully certified to work their position again, but it's still a pretty big deal to the ATCers I know. Maintenance personnel can also have their certificates suspended, though that tends to be more rare than being sued. (ATC is prevented from being sued in almost all circumstances, so that doesn't apply to them.) You can be sure that most fatal crashes result in at least an investigation of logbooks, who signed off the aircraft and for what, and some utterly absurd civil cases, many of which are settled without regard to the facts of the case but based on the perceived depth of pocket of the defendant.
paol 11y ago
You're right that there's a natural alignment of incentives between pilots and their passengers, but as wnevets points out above there are other critical participants in the system that aren't travelling in the plane. Your "binary nature of problems" comment is wrong though. First common misconception: statistically the most probable outcome for someone involved in an airplane crash is survival, not death [0]. Second misconception: investigations routinely happen for incidents not resulting in crashes. In fact the whole point of promoting self-reporting of incidents by pilots is so that such investigations can be conducted for incidents that would otherwise never be known. [0] https://app.ntsb.gov/doclib/safetystudies/SR0101.pdf https://app.ntsb.gov/doclib/safetystudies/SR0101.pdf
- ksdale 11y ago
  That's a very excellent point about other critical participants. I appreciate the additional information! I didn't mean to sound like I thought that people die all the time in airplane crashes, merely that the median mistake is way less likely to affect a passenger, which is a major criteria for deciding to punish in other professions. Every mistake a lawyer or doctor makes can hurt clients or patients, respectively, whereas for most mistakes a pilot makes, no one will even know they made it (except if they self report, which they do a lot as you pointed out). And then I added in the ill-advised part about dying, by which I was really trying to communicate that the really bad outcomes are so bad that punishment is the last thing on people's minds.
  - paol 11y ago
    > punishment is the last thing on people's minds I wish. Just off the top of my head, there was the swiss air traffic controller who was murdered by some relative of one of the victims of a mid-air collision [0], and the Brazilian government trying to put the surviving crew of another mid-air collision on trial [1]. Someone with better memory could surely think of more examples. [0] https://en.wikipedia.org/wiki/%C3%9Cberlingen_mid-air_collision https://en.wikipedia.org/wiki/%C3%9Cberlingen_mid-air_collis... [1] https://en.wikipedia.org/wiki/Gol_Transportes_A%C3%A9reos_Flight_1907 https://en.wikipedia.org/wiki/Gol_Transportes_A%C3%A9reos_Fl...
Eric_WVGG 11y ago
not exactly an aviation example, but applicable: the space shuttle Challenger tragedy was not caused by pilot error.
- 0xdeadbeefbabe 11y ago
  Yes and Columbia.
deleted 11y ago
[deleted]

zardo 11y ago

We (try to) have a similar attitude about mistakes at our manufacturing facility. Even if the problem is employee did not follow instructions, the real problem is that the instructions were complicated, or they were only given once, or we don't have a check in place to verify the instruction was followed. Blaming people doesn't fix things.

nkrisc 11y ago
That's a great example. The goal is to modify behavior, and to do so you need to understand the conditions that lead to the undesirable behavior and change those conditions. Barring outright intentional malice, there's usually a good reason someone did (or did not do) something.
- ThrustVectoring 11y ago
  I'd phrase it as "to modify future behavior", to emphasize that absolutely nothing you do can change what happened.
  - nkrisc 11y ago
    Yes, exactly! I think that's sort of the key thing about the aviation approach. You can't change what happened so there's not much point in blaming people. Assigning blame and punishment is one way of attempting to modify future behavior, though not always effective.

maxcan 11y ago

This is very true. The FAA really takes this seriously. So much so that since one of their duties is enforcement and potentially revoking licenses for violations they have built a system where NASA, a completely separate agency, manages the Aviation Safety and Reporting System (ASRS). When we, as pilots, submit ASRS reports of mistakes or dangerous situations we know that the information we submit on those reports cannot and will not be used against us in a FAA violation proceeding. Furthermore, submission of an ASRS report will often reduce or eliminate any penalties for an infraction. This has created a cover-your-ass-culture that actually promotes safety as we will often report mistakes and dangerous situations early and aggressively, knowing that we are protected from FAA action and for commercial pilots, from airline disciplinary processes.

petra 11y ago
This system is working great. But what about bad pilots ? How are they dealt with ?
- curun1r 11y ago
  I'm not a pilot, but I'd imagine that it's a combination of recognizing and learning from each mistake and a ruthless punishment of severe mistakes. If you have a culture of reporting each and every mistake, you can receive feedback on what you could have done better in each and every one of those situations. That leads to bad pilots constantly becoming better pilots. Additionally, unlike the doctors in the story, severe mistakes in aviation will result in the death of the pilot, so like those startups that always fire the bottom percentage of their workforce, the really bad pilots will naturally eliminate themselves. Rockclimbing is similar to flying in their compulsion to study fatal accidents. Climbing magazines will publish fairly in-depth discussions, not out of morbid curiosity but, instead, as a campaign to build awareness among climbers of mistakes that can kill them. This has led to safer gear and practices used in the sport and has undoubtedly saved lives.
- avn2109 11y ago
  By definition, the bad pilots have or will soon crash their aircraft, removing either themselves or at least their equipment (and unfortunately maybe their passengers) from circulation. I say this as myself a bad pilot, but one who is aware enough of that fact to always fly with dual control.

js8 11y ago

> Only the final goal of improving outcomes matters, and indulging the emotional human demand for punishment does not necessarily help that goal, it can even seriously hinder it. If only we could apply the same rationality to, say, the penal system. I completely agree. Humanity still has to grow up, to realize that helping other people is lot more efficient than punishment. I like the quote: "Emphasis on punishment is the sign of an obedience frame."

CaptSpify 11y ago

One thing I've learned in my career: Whenever there is a failure, it's almost always caused by more than one mistake. The root-cause could be someone not paying attention, but if that mistake can be disastrous, you shouldn't be relying on that one-point of failure. If "finding someone to blame" is the solution to a problem, your org has failed in more ways than one. I've had mixed experiences, but I find the orgs that set up roadblocks to prevent single-mistakes from causing issues are much better off.