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Somewhat off topic, but as someone with an interest in aviation I enjoy reading the aviation safety reports, like the aaib reports [0], airprox reports [1] or t

Somewhat off topic, but as someone with an interest in aviation I enjoy reading the aviation safety reports, like the aaib reports [0], airprox reports [1] or the CHIRP newsletters [2]. (All UK based) I try to find a similar 'tone of voice' when conducting or participating in RCA's for incidents during my day job [0] https://www.gov.uk/aaib-reports https://www.gov.uk/aaib-reports [1] https://www.airproxboard.org.uk/Reports-and-analysis/Monthly-summaries/Monthly-Airprox-reviews/ https://www.airproxboard.org.uk/Reports-and-analysis/Monthly... [2] https://www.chirp.co.uk/ https://www.chirp.co.uk/

sokoloff 11y ago
> I try to find a similar 'tone of voice' when conducting or participating in RCA's for incidents during my day job Me as well though, as a pilot, I find that the NTSB is a little too free in about 10% of cases in assigning blame to the flight crew as the primary cause. Yes, most crashes are crew-caused, but I've read many where the crew gets the blame as primary rather than as secondary. In my day job, I've also brought in the concepts of FAR 91.3 and have explicitly given that level of authority to the team responsible for running our production systems. FAR 91.3 reads: Responsibility and authority of the pilot in command. (a) The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft. (b) In an in-flight emergency requiring immediate action, the pilot in command may deviate from any rule of this part to the extent required to meet that emergency. (c) Each pilot in command who deviates from a rule under paragraph (b) of this section shall, upon the request of the Administrator, send a written report of that deviation to the Administrator. The intent is to make clear to the team that they have the final say and that, while I may make inquiries later as to why they made a certain deviation from our norms, SOPs, or policies, that they do have the right to do so, and that all I'm able to ask for is a report. Couple this with demonstrated blameless treatment of post-mortems and you get a pretty good outcome out of good people. We do want to know exactly WHO did WHAT, WHEN, HOW, and WHY, but we use to introspect and make the future better, not to punish.
ksrm 11y ago
You might also enjoy the Rail Accident Investigation Branch's reports. They are written in a similar style. https://www.gov.uk/raib-reports https://www.gov.uk/raib-reports

sokoloff 11y ago

> I try to find a similar 'tone of voice' when conducting or participating in RCA's for incidents during my day job Me as well though, as a pilot, I find that the NTSB is a little too free in about 10% of cases in assigning blame to the flight crew as the primary cause. Yes, most crashes are crew-caused, but I've read many where the crew gets the blame as primary rather than as secondary. In my day job, I've also brought in the concepts of FAR 91.3 and have explicitly given that level of authority to the team responsible for running our production systems. FAR 91.3 reads: Responsibility and authority of the pilot in command. (a) The pilot in command of an aircraft is directly responsible for, and is the final authority as to, the operation of that aircraft. (b) In an in-flight emergency requiring immediate action, the pilot in command may deviate from any rule of this part to the extent required to meet that emergency. (c) Each pilot in command who deviates from a rule under paragraph (b) of this section shall, upon the request of the Administrator, send a written report of that deviation to the Administrator. The intent is to make clear to the team that they have the final say and that, while I may make inquiries later as to why they made a certain deviation from our norms, SOPs, or policies, that they do have the right to do so, and that all I'm able to ask for is a report. Couple this with demonstrated blameless treatment of post-mortems and you get a pretty good outcome out of good people. We do want to know exactly WHO did WHAT, WHEN, HOW, and WHY, but we use to introspect and make the future better, not to punish.

ksrm 11y ago

You might also enjoy the Rail Accident Investigation Branch's reports. They are written in a similar style. https://www.gov.uk/raib-reports https://www.gov.uk/raib-reports