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I am not an expert but I know many pilots, watch only documentaries, read research papers almost exclusively, and have stayed in a Best Western. NTSB is, as far as I understand, actually very careful about not blaming anyone. They look for causes and solutions, not blame. They, as far as I know, pride themselves on this. They try, again inasmuch as I know, to not blame a person - but to blame a process. This is not a distinction without difference. It fosters an attitude of cooperation and openness. Again, I'm not an expert but I know a bunch of pilots and listen when they speak. If the NTSB blamed people, I suspect they'd have a lesser willingness to speak positively about NTSB. Edit: Someone beat me to it. I will leave this as I think it offers a bit more of a comprehensive view. |
Because even when the cause was blatant human error, it can still be a process problem -- how did this type of human error slice through all the protections against it? What process can be put into place to prevent disaster even when some bonehead does that same thing again?
But air travel safety is atypical.
If the crash rate for planes was the same as it is for cars then air travel would have to be prohibited as a necessary measure to prevent the extinction of the human race.
Most endeavors are not of that sort.
And so in most other contexts we could use their methods to produce a process that will prevent a particular category of trouble, but suffering the trouble costs $2M (instead of $2B) and implementing the process costs $20M.
And then people will want to implement it anyway, even though they shouldn't, because "it solves the problem".
Or, seeing the obvious fallacy in spending $20M to prevent $2M in harm, a "compromise" is proposed to spend $1M to prevent 5% of the $2M harm, still with no one doing the math. And then, problem still 95% unsolved, more half measures are kludged on over time until the surrounding bureaucracy becomes politically powerful enough to be self-sustaining.
Because people don't want to admit that some diseases aren't worse than their cures.