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Being at fault doesn't mean you're being blamed. It would be really stupid to have a postmortem if nobody is indicated as having done something wrong. A pilot

Being at fault doesn't mean you're being blamed. It would be really stupid to have a postmortem if nobody is indicated as having done something wrong. A pilot may have made an error and been at-fault, but blamelessness means that you focus on preventing the issues that led to them making the error. The point is to acknowledge that humans make errors and to fix the conditions that allowed the human error to take place to begin with. The point is not to avoid identifying who made the error. Of course, gross negligence is still deserving of punishment, especially when lives are at stake.

ncallaway 4y ago
> It would be really stupid to have a postmortem if nobody is indicated as having done something wrong. This sounds wrong to me. If the processes in place allow an incident when everyone is properly following the process, that seems like the most important time for a postmortem, since the existing process clearly is insufficient and must be adjusted.
- thaumasiotes 4y ago
  The processes in place everywhere always allow for an incident to occur when everyone is properly following the process. The alternative is impossible; you cannot specify any process that prevents the occurrence of incidents.
- bastawhiz 4y ago
  But if someone wasn't following the process, and you avoid stating that they made an error for the sake of blamelessness, you're avoiding talking about how the incident occurred. That doesn't mean the process doesn't need fixing.
Tomte 4y ago
"Nobody done wrong" happens in aviation accident investigations. I remember one about a collision between a Bundeswehr fighter jet and a glider over the Black Forest. The detailed report found that both aircraft were where they were allowed to be, the fighter pilot had little chance to see the glider, and it was an unfortunate event. The report ended with "Recommendations: None" (https://www.bfu-web.de/DE/Publikationen/Untersuchungsberichte/1998/Bericht_3X191-1-2.98.pdf?__blob=publicationFile https://www.bfu-web.de/DE/Publikationen/Untersuchungsbericht...)

ncallaway 4y ago

> It would be really stupid to have a postmortem if nobody is indicated as having done something wrong. This sounds wrong to me. If the processes in place allow an incident when everyone is properly following the process, that seems like the most important time for a postmortem, since the existing process clearly is insufficient and must be adjusted.

thaumasiotes 4y ago
The processes in place everywhere always allow for an incident to occur when everyone is properly following the process. The alternative is impossible; you cannot specify any process that prevents the occurrence of incidents.
bastawhiz 4y ago
But if someone wasn't following the process, and you avoid stating that they made an error for the sake of blamelessness, you're avoiding talking about how the incident occurred. That doesn't mean the process doesn't need fixing.

Tomte 4y ago

"Nobody done wrong" happens in aviation accident investigations. I remember one about a collision between a Bundeswehr fighter jet and a glider over the Black Forest. The detailed report found that both aircraft were where they were allowed to be, the fighter pilot had little chance to see the glider, and it was an unfortunate event. The report ended with "Recommendations: None" (https://www.bfu-web.de/DE/Publikationen/Untersuchungsberichte/1998/Bericht_3X191-1-2.98.pdf?__blob=publicationFile https://www.bfu-web.de/DE/Publikationen/Untersuchungsbericht...)