>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.