How the authorities choose to handle such a mistake says a lot about our society’s conceptions of justice, culpability, agency, empathy, and even vengeance, because the moral dilemma of what to do about Robin Wascher exists as a struggle between diverging values and, in fact, diverging value systems, rooted in the relative prioritization of individual and systemic responsibility.
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The end result was that the aviation industry became one of the first to embrace the concept of a “blameless postmortem” as a legally codified principle underpinning all investigations. In 1951, compelled by the reality that their industry was not widely regarded as safe, aviation experts from around the world gathered to compose Annex 13 to the Chicago Convention on International Civil Aviation. This seminal document aimed to standardize the conduct of air accident investigations among all member states of the International Civil Aviation Organization. Annex 13 holds that the primary purpose of an aircraft accident investigation is to prevent future accidents — a decision that implicitly privileged prevention above the search for liability. Conducting a police-style investigation that faults a deceased pilot does nothing to affect the probability of future accidents. To follow the spirit of Annex 13, investigators must ask how others could be prevented from making the same mistakes in the future.
- No location available
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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.”When liability is not a concern, an investigation has leeway to draw more meaningful conclusions.
- No location available
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Humans are fallible creatures who make poor decisions, misinterpret data, and forget things. In a system where lives may depend on the accuracy of a single person, disaster is not only probable but, given enough time, inevitable.
- No location available
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The key takeaway from the success of this approach is that safety improvements are best achieved when an honest mistake is treated as such, regardless of the consequences. This principle underpins what is known in several advanced industries as the “just culture” concept. A just organizational culture recognizes that a high level of operational safety can be achieved only when the root causes of human error are examined; who made a mistake is far less important than why it was made. A just culture encourages self-reporting of errors in order to gather as much data about those errors as possible. In contrast, an organization without a just culture will be left unaware of its own vulnerabilities because employees hide their mistakes for fear of retribution. Such an organization will discover those vulnerabilities only when they result in consequences that are impossible to hide.
- No location available
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Sometimes disasters happen anyway, and when they do, it’s equally critical that the just culture is upheld. Although it can be hard to accept that a mistake that led to loss of life might go unpunished, just culture doesn’t permit us to discriminate based on the magnitude of the consequences — only on the attitude of the person who committed the error. If they were acting in good faith when the mistake occurred, then a harsh reaction would undermine the trust between employees and management that facilitates the just culture. But even more importantly, it would undermine the blameless investigative process that makes modern aviation so safe. Investigative agencies like the NTSB rely on truthful statements from those involved in an accident in order to determine what happened and why, and the truth can’t be acquired when individuals fear punishment for speaking it.
- No location available
-

How the authorities choose to handle such a mistake says a lot about our society’s conceptions of justice, culpability, agency, empathy, and even vengeance, because the moral dilemma of what to do about Robin Wascher exists as a struggle between diverging values and, in fact, diverging value systems, rooted in the relative prioritization of individual and systemic responsibility.
- No location available
-

The end result was that the aviation industry became one of the first to embrace the concept of a “blameless postmortem” as a legally codified principle underpinning all investigations. In 1951, compelled by the reality that their industry was not widely regarded as safe, aviation experts from around the world gathered to compose Annex 13 to the Chicago Convention on International Civil Aviation. This seminal document aimed to standardize the conduct of air accident investigations among all member states of the International Civil Aviation Organization. Annex 13 holds that the primary purpose of an aircraft accident investigation is to prevent future accidents — a decision that implicitly privileged prevention above the search for liability. Conducting a police-style investigation that faults a deceased pilot does nothing to affect the probability of future accidents. To follow the spirit of Annex 13, investigators must ask how others could be prevented from making the same mistakes in the future.
- No location available
-

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.”When liability is not a concern, an investigation has leeway to draw more meaningful conclusions.
- No location available
-

Humans are fallible creatures who make poor decisions, misinterpret data, and forget things. In a system where lives may depend on the accuracy of a single person, disaster is not only probable but, given enough time, inevitable.
- No location available
-

The key takeaway from the success of this approach is that safety improvements are best achieved when an honest mistake is treated as such, regardless of the consequences. This principle underpins what is known in several advanced industries as the “just culture” concept. A just organizational culture recognizes that a high level of operational safety can be achieved only when the root causes of human error are examined; who made a mistake is far less important than why it was made. A just culture encourages self-reporting of errors in order to gather as much data about those errors as possible. In contrast, an organization without a just culture will be left unaware of its own vulnerabilities because employees hide their mistakes for fear of retribution. Such an organization will discover those vulnerabilities only when they result in consequences that are impossible to hide.
- No location available
-

Sometimes disasters happen anyway, and when they do, it’s equally critical that the just culture is upheld. Although it can be hard to accept that a mistake that led to loss of life might go unpunished, just culture doesn’t permit us to discriminate based on the magnitude of the consequences — only on the attitude of the person who committed the error. If they were acting in good faith when the mistake occurred, then a harsh reaction would undermine the trust between employees and management that facilitates the just culture. But even more importantly, it would undermine the blameless investigative process that makes modern aviation so safe. Investigative agencies like the NTSB rely on truthful statements from those involved in an accident in order to determine what happened and why, and the truth can’t be acquired when individuals fear punishment for speaking it.
- No location available
-