This is the first time I've heard of "just culture" and wish it would spread to other areas of the world and life.
This is all done in such a smart, seamless, obvious way to deliver a lesson that would make the Brothers Grimm feel cheated.
Strongly recommend.
https://www.youtube.com/watch?v=2sIzfGzf_50
Related, I recommend that teams subject to SOX-404 controls consider adopting a variant of FAR 91.3*. Our SOX docs explicitly permit our incident managers (and two additional high-level tech employee roles) to authorize any action they deem justified during a production emergency.
* - https://www.ecfr.gov/current/title-14/chapter-I/subchapter-F...
It specifically won't work for things which were not accidents at all, where blame remains a useful tool.
There's some nuance, the Captain of the Titanic didn't intend to sink the ship and kill loads of people, in that sense it was an accident - but he also didn't need to head into an ice field at full speed. Various UK politicians didn't set out to drive postmasters to suicide, but they did give political cover to business people they must have suspected weren't being truthful.
In software I've seen "blameless" mean "people who outright broke the process and in some cases even law should not take any blame".
Any decent accident investigation should highlight that the Captain was under strict instructions from the ship owners to break a record, wealthy influential owners that could and would destroy his career if he failed to push the ship.
Good investigations identify causes with a view to prevent repetition of circumstances.
Cases like these (Titanic, UK Post) strengthen the case for whistle blower protection.
Captains being pressured by mamagement / organization to do hazardous stuff is a thing still, in aviation as well as in seafaring.
Unfortunately the thing most people remember (and which you highlighted) is life boats and, perhaps those are actually a bad idea, at least for most ships.
Here's how that goes: SOLAS requires life boats, but almost always you won't use them. Titanic is a rare example of a situation where life boats are very useful, an ocean linear breaks apart in the middle of the ocean. In most cases you're not very far from land, and so almost always you just get the people onto land and maybe the ship is damaged/ destroyed or maybe not, that's just stuff and it's insured. Fire? Control the fire, go to port. Hole in the ship? Pumps control sinking, go to port. Engine failure? Tow the ship to port. So in all these cases you don't use the life boats, doing so is basically a last resort.
But, even though you would very rarely need them, likely never for a vessel which operates close to shore, they must be maintained periodically because SOLAS, and maintenance of lifeboats is pretty dangerous because they're on the outside of a ship. So you may end up killing or seriously injuring more people by having lifeboats.
But, even though you would very rarely need them, likely never for a vessel which operates close to shore, they must be maintained periodically because SOLAS, and maintenance of lifeboats is pretty dangerous because they're on the outside of a ship. So you may end up killing or seriously injuring more people by having lifeboats.
Titanic is the sweet spot for wanting more lifeboats, they had a long time, but they were in the middle of the ocean and nobody was coming to help.
If you go down very quickly lifeboats are useless. Herald of Free Enterprise could have had ten lifeboats per customer, wouldn't have made a difference, there were 90 seconds between nothing is wrong, and oops the ship is laying on its side in the water, lots of people are going to die in that scenario.
On the other hand if the port isn't far you can make for port. Despite a ship being on fire, or badly holed it may have hours left, the Titanic had almost three hours.
1: That life boat maintenance is dangerous (anyway, for such a claim I'd expect numbers)
2: Directly comparing any death (!) happening during vessel maintennace and operation with lives saved during an vessel accident
Usually not worth further engaging with thisbkind of thinking online.
They didn't argue that the maintenance is bad because its expensive. How could you miss that point? You literally quoted it in your comment:
> > ... dangerous ...
https://www.cbsnews.com/news/el-faro-freighter-ship-hurrican...
* It expects everybody in the organization to be earnest rule-followers doing the best they can to achieve the goals of their organization. The uncaring, reckless, rebellious, etc people have been screened out of the organization long before it gets to that point.
* It expects that the whole organization has cultural unity. Nobody is trying to hoard status, power, influence, etc for one subset of the organization at the expense of another.
* It expects that the organization as a whole is not, and does not perceive itself to be, under attack from hostile outside forces. Organizations can effectively fear being blamed and destroyed just as well as individuals can.
But of course, it's easier to wring our hands over not having the perfect culture to implement what was itself the culture-builder than to actually put in the decades of work required.
As an aside, I think a lot of readers would be better served by setting aside their existing notions of what "blameless" means and looking into what it _actually_ means for the industry in question.
If one concentrates on blaming individuals, the system is not fixed.