Focus on punishing people and one, you teach people to be better at avoiding punishment and two, you keep punishing new people for doing the same thing over and over.
It's not the kind of thing where you make a change and planes fall out of the sky. No, you make small, gradual changes in processes and in safety margins until at some point in the distant future, planes fail catastrophically as a direct result of decisions made as an organization 1-3 decades ago. It's the same set of behaviors that led to the Challenger disaster.
Air travel is very safe because the entire world of aviation has focused on analysis and improvement rather than infighting and blaming. If anything, I worry more about how the aviation community worldwide seems to be fragmenting right now, and the effect that may have on safety going forward.
But then I do read stories about the FAA and EASA still cooperating very tightly and respectfully, realize most of the infighting is by armchair quarterbacks on the Internet and the pros are still doing the Right Thing, and I sleep a little better.
Except you have one institution, the FAA, and one company, Boeing, who clearly no longer have a focus on maintaining regulatory processes to keep safety the main priority. While Boeing is cutting corners everywhere in order to save a buck, the FAA is looking the other way and letting Boeing do what they want. This is something that has already had serious consequences, and will continue to unless there are serious changes on a systemic level and there are punishments for those who are responsible for allowing these systemic changes to have occurred.
Also, I don't appreciate your underhanded insult. This isn't the place for it.
Sorry you took that as an insult, it was not intended as such. It's a generic observation that on places like HN we've collectively lost our shit and started acting like we are aeronautical engineers. It's actually one of the big factors that has recently caused me to lose a lot of confidence in the HN crowd. Thought we were above it. Even in middle age it seems I'm still capable of wide-eyed naivete.
Things are getting a little heated, so I just figured I'd chime in, because I've unintentionally become a bit of an expert on this.
It is correct that blameless postmortem has been a major contributor to the culture of aviation safety. I don't necessarily question that culture so much as the prevailing executive culture at Boeing since the McDonnell Douglas merger.
https://www.mymoneyblog.com/boeing-engineer-dream-job-nightm...
https://www.bloomberg.com/news/features/2019-05-09/former-bo...
In that case, the aviation safety culture is being undermined by executive pressure, which has been a more recent thing as far as I'm aware from my aviation history deep dive. Boeing only after the merger showed signs of trying to "financially engineer" the company into a vessel of shareholder value growth over and above it's primary mission of making safe, high quality aircraft.
In regards to >It's a generic observation that on places like HN we've collectively lost our shit and started acting like we are aeronautical engineers.
They who grapple with questions and issues of aeronautical engineering, who run down facts, find evidence, employ sound reasoning to make predictions are, de facto aeronautics engineers in the sense of people doing tasks normally being associated with the responsibility of a practicing aeronautical engineer.
They are not a protected class of people, and anyone willing to pick up the tools and use them correctly, basically is one. The protected class is a Professional Engineer (U.S. not sure about anywhere else), who has been granted authority by the State to sign off on Engineering projects.
The elitism communicated by calling someone out for not being a practitioner in their day job is not desirable or conducive to fruitful discussion, and is regularly frowned upon.
One doesn't pop out of the womb an engineer after all, so drawing such lines only serves to discourage inquisitive minds.
IF a company shortchanges safety to beat someone to market...
I think a good look at corporate personhood is in order. If a company causes deaths due to their rush to get a product to market, charge the company, and if guilty, the board at the time of the crime must serve the sentence.
Do that, and you'd see a lot less shitty behavior from corporations.
But that doesn’t get you safety or improvements. You can’t test anything infinitely, you can’t predict the future, all you can do is have standards and processes and a willingness to learn from mistakes.
Putting the “bad guys” away doesn’t help anybody decide when ready is ready. Turning collections of mistakes into crimes doesn’t prevent future mistakes.
Fear doesn’t prevent mistakes it encourages them.
Looking at everything that goes wrong as a crime makes more go wrong not less.
Yes, it does, because it makes people accountable for their actions and makes them fear punishment, so they'll avoid criminal actions in the first place.
>You can’t test anything infinitely, you can’t predict the future, all you can do is have standards and processes and a willingness to learn from mistakes.
Sounds great, so why didn't Boeing and the FAA do that? That's the thing that makes them criminally liable.
"Bad guys" are supposed to get put away when they intentionally do things that get people hurt or killed. This is called "criminal negligence", which is what Boeing is guilty of. People don't go to jail for mere accidents; they have to be proven beyond a reasonable doubt to have acted negligent to a criminal degree (i.e., usually intentionally). Boeing intentionally made design decisions that were contrary to safety, and then intentionally tried to hide what had happened and keep the planes in the air even though they were deadly.
>Turning collections of mistakes into crimes doesn’t prevent future mistakes.
Yes, it does, when those "mistakes" were criminal negligence. That's why we have laws that makes these mistakes criminal.
Look at police and healthcare to see how badly your strategy works.
You are passing a lot of judgement with almost no information besides a few newspaper articles cashing in on the public interest by speculating.
I am either not selling the idea of an open culture towards failure very well or such conversations really attract people who like blame, vengeance, and pitchforks.
>You are passing a lot of judgement with almost no information besides a few newspaper articles cashing in on the public interest by speculating.
Bullshit. There has been more that sufficient information unearthed in the last half-year or so about the criminal negligence that Boeing committed, and how the FAA simply looked the other way. This is not arguable at this point.
You are just so incredibly certain. Why have investigations at all, magduf knows. And after the blaming and punishment is decided, people with that attitude don’t care about the issue any more. Problem solved until the next thing happens and we need to hang somebody new.
Do you work for Boeing or something?
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).
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.
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.