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Do you have any sources for that? I'd agree with the GP: one reason for the astounding safety in aviation is the conscious decision to leave blame and criminali

by FabHK 7y ago

Do you have any sources for that? I'd agree with the GP: one reason for the astounding safety in aviation is the conscious decision to leave blame and criminalisation out of the picture, and focus instead on the causes and prevention of accidents. What you wrote goes against everything I know about aviation safety. As an example, every NTSB report comes with this explicit disclaimer: > The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties ... and are not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4. Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages resulting from a matter mentioned in the report. 49 U.S.C. § 1154(b).

magduf 7y ago
>What you wrote goes against everything I know about aviation safety. You think "aviation safety" means that outright criminal negligence should go unpunished? That goes against all common sense.
- colechristensen 7y ago
  >You think "aviation safety" means that outright criminal negligence should go unpunished? That goes against all common sense. Ultimately, mostly. It requires you to think bigger, to expect mistakes and wrongdoing, and focus on ways to prevent the ultimate effect “plane crash” and not an intermediate cause (mistakes, negligence, fraud, laziness, stupidity, random acts of god, etc) You have to think of humans as part of the system and failure too. Humans fail just like steel beams fail. You need to engineer for it and not blame your tools and materials when your system fails, but how the system is designed instead (and not by fixing the designers by putting them in jail but by fixing the design) You do this by striving to understand failures when they happen (not by pointing fingers and insisting on prison) As you understand individual causes of failure you look back a step further and a step further until you are satisfied that youve fixed the immediate problem and everything that let it happen. You don’t stop when you find out that Bob is lazy and a liar and didn’t do his job. It’s naive and dangerous to think that there won’t be another Bob next time or that whatever you do to punish Bob will eliminate all Bobs from the future forever. You want to fix what design principles weren’t there that led to the faulty design, then the tests that didn’t catch it, then the testing requirements that didn’t make appropriate tests, then the auditing that didn’t catch the laps, then the acceptance tests, pilot reporting pipeline and prioritization, incident response lapses, missing regulation, missing enforcement audit, wrong training, missing law, missing insurance requirement, missing risk notification, change notification, process overcomplexity analysis, and on and on and on. Flying people around is hugely complex and involves many many actors. Too many of them to say the buck stops anywhere. Every responsibility for correct action is shared over several organization and thousands of people. Finding which ones to hang is counterproductive to safety if you’re actually trying to improve because it’s a distraction and theres never one single point of failure, there are a whole series of things that have to go wrong and if they do and it is actually only a few people responsible then it is everyone’s fault for being foolish enough for letting it get that way. Punishment can be there as an afterthought for particularly egregious acts, but if it os the main focus you are accepting and encouraging failure and ensuring that regularly you will be hanging Bobs in the village square.
  - magduf 7y ago
    All that stuff you talk about here about design principles, testing, etc., don't actually work when the people at the very top, both at the manufacturer and at the FAA are actively working to undermine it. That's why people have to be punished. We're not talking about a case where some rank-and-file engineers were a little lazy, or where some worker on the assembly line screwed up; we're talking about a case where the top executives directed the entire company to design an unsafe plane, and then collaborated with the regulatory agency to certify it as safe even though it wasn't. You can't fix that with processes, the way you can deal with errors by lower-level people. You have to hold people accountable and punish them, because these actions were willful, criminal negligence.
salawat 7y ago
Keep in mind the NTSB is a fact finding organization. They don't care, and in fact the protections you mention are there to ensure everyone has every reason to be honest. If there is any evidence of criminal negligence, it won't be in the facts of what happened. It'll be in the signals and narratives spelled out by the information revealed by any criminal probes of Boeing. The aviation safety culture can have it's cake in this regard, but in order to eat it as a society, we still need an accountability mechanism for those with the position to destructively influence industry structures through malignant optimization techniques, which unfortunately, is squarely consolidated within Boeing's wheelhouse. That's two separate mechanisms being reasoned about. One, the NTSB answers "What the #$@! happened?" The criminal probe will need to be able to uncover a beyond a reasonable doubt answer of "Why the #$@! did this happen, and who was ultimately involved?" I'm not necessarily holding my breath anyone will ultimately be found accountable, but that the investigation is happening at all may be enough to discourage the behavior for the most part. I've been wrong before though.

by FabHK 7y ago

magduf 7y ago

>What you wrote goes against everything I know about aviation safety. You think "aviation safety" means that outright criminal negligence should go unpunished? That goes against all common sense.

colechristensen 7y ago
>You think "aviation safety" means that outright criminal negligence should go unpunished? That goes against all common sense. Ultimately, mostly. It requires you to think bigger, to expect mistakes and wrongdoing, and focus on ways to prevent the ultimate effect “plane crash” and not an intermediate cause (mistakes, negligence, fraud, laziness, stupidity, random acts of god, etc) You have to think of humans as part of the system and failure too. Humans fail just like steel beams fail. You need to engineer for it and not blame your tools and materials when your system fails, but how the system is designed instead (and not by fixing the designers by putting them in jail but by fixing the design) You do this by striving to understand failures when they happen (not by pointing fingers and insisting on prison) As you understand individual causes of failure you look back a step further and a step further until you are satisfied that youve fixed the immediate problem and everything that let it happen. You don’t stop when you find out that Bob is lazy and a liar and didn’t do his job. It’s naive and dangerous to think that there won’t be another Bob next time or that whatever you do to punish Bob will eliminate all Bobs from the future forever. You want to fix what design principles weren’t there that led to the faulty design, then the tests that didn’t catch it, then the testing requirements that didn’t make appropriate tests, then the auditing that didn’t catch the laps, then the acceptance tests, pilot reporting pipeline and prioritization, incident response lapses, missing regulation, missing enforcement audit, wrong training, missing law, missing insurance requirement, missing risk notification, change notification, process overcomplexity analysis, and on and on and on. Flying people around is hugely complex and involves many many actors. Too many of them to say the buck stops anywhere. Every responsibility for correct action is shared over several organization and thousands of people. Finding which ones to hang is counterproductive to safety if you’re actually trying to improve because it’s a distraction and theres never one single point of failure, there are a whole series of things that have to go wrong and if they do and it is actually only a few people responsible then it is everyone’s fault for being foolish enough for letting it get that way. Punishment can be there as an afterthought for particularly egregious acts, but if it os the main focus you are accepting and encouraging failure and ensuring that regularly you will be hanging Bobs in the village square.
- magduf 7y ago
  All that stuff you talk about here about design principles, testing, etc., don't actually work when the people at the very top, both at the manufacturer and at the FAA are actively working to undermine it. That's why people have to be punished. We're not talking about a case where some rank-and-file engineers were a little lazy, or where some worker on the assembly line screwed up; we're talking about a case where the top executives directed the entire company to design an unsafe plane, and then collaborated with the regulatory agency to certify it as safe even though it wasn't. You can't fix that with processes, the way you can deal with errors by lower-level people. You have to hold people accountable and punish them, because these actions were willful, criminal negligence.

salawat 7y ago

Keep in mind the NTSB is a fact finding organization. They don't care, and in fact the protections you mention are there to ensure everyone has every reason to be honest. If there is any evidence of criminal negligence, it won't be in the facts of what happened. It'll be in the signals and narratives spelled out by the information revealed by any criminal probes of Boeing. The aviation safety culture can have it's cake in this regard, but in order to eat it as a society, we still need an accountability mechanism for those with the position to destructively influence industry structures through malignant optimization techniques, which unfortunately, is squarely consolidated within Boeing's wheelhouse. That's two separate mechanisms being reasoned about. One, the NTSB answers "What the #$@! happened?" The criminal probe will need to be able to uncover a beyond a reasonable doubt answer of "Why the #$@! did this happen, and who was ultimately involved?" I'm not necessarily holding my breath anyone will ultimately be found accountable, but that the investigation is happening at all may be enough to discourage the behavior for the most part. I've been wrong before though.