I am by no means an expert on this subject so correct me if I'm wrong but....

The exception that I've noticed from the airline-industry, is that they actually want to solve problems systemically and don't care who has to take the blame.

For something to go wrong, multiple failures have to happen, and there's not a lot of blame put on individuals, as much as "the process".

In most other organizations, IME, fixing "the process" is expensive. It takes time, and effort, and it's quicker and easier to blame "those idiots in IT/accounting/HR/etc". Most of those types of organizations don't actually want to solve problems, they just want the problem to go away. So they end up choosing the easier option, rather than dealing with the problem systematically.

/bitter rant

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.

> 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.

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.

> 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.

Well, no, this is obviously false. Much more car travel is done than air travel; bringing air fatalities up to the level of car fatalities would have a negligible effect on the human population.

Bringing crashes per vehicle mile up to the level of highway crashes per vehicle mile according to https://www.rita.dot.gov/bts/sites/rita.dot.gov.bts/files/pu..., assuming that an average airplane carries 140 people, and assuming (very wrongly) that crashing it kills all 140, you could get deaths to airplane crashes up to 843,000 per year for the US. This would be significant -- it would be an increase of over 30% in the annual death rate -- but it is less than the existing surplus of annual births over annual deaths. A modest reduction in population growth just isn't going to drive the human race extinct.

You're assuming the existing expense of making air travel safe is not reducing the quantity of air travel done.

Imagine it was as easy to become a pilot as to get a driver's license, there were no flight plans or restrictions on where people could take off or land and a 500MPH jet could be purchased for $150,000 because there would be less regulatory overhead and more competition in aircraft production.

Affluent people would be commuting by jet. There could easily be ten times as many air miles traveled or more.

If you want to "reason" that way, take into account that (1) if people started dying from air travel at high rates, they'd do less of it; and (2) societies with much higher death rates have no problem growing anyway, as they compensate with higher birth rates.

> if people started dying from air travel at high rates, they'd do less of it

That doesn't seem to stop people from driving cars.

> societies with much higher death rates have no problem growing anyway, as they compensate with higher birth rates.

That's just survivorship bias. Why would one cause the other? There were also societies with high death rates and low birth rates which for the obvious reason no longer exist.

> There were also societies with high death rates and low birth rates which for the obvious reason no longer exist.

If you claim to be worried about extinction of the human race, you'll have to consider all societies, not just the ones with pathologically low birth rates. A tiny group of people committing suicide has zero effect on the overall human population.

>They look for causes and solutions, not blame. They, as far as I know, pride themselves on this.

If the cause is a person's behavior, that is the same thing as blame. Look at the report of the Pinnacle 3701. Probable causes from [1]:

1. the pilots' unprofessional behavior, deviation from standard operating procedures, and poor airmanship;

2. the pilots' failure to prepare for an emergency landing in a timely manner, including communicating with air traffic controllers immediately after the emergency about the loss of both engines and the availability of landing sites;

3. the pilots' improper management of the double engine failure checklist

It's hard to look at that and say that the pilots weren't being blamed.

1. https://en.wikipedia.org/wiki/Pinnacle_Airlines_Flight_3701

It does happen, but is the exception. Look at the aftermath section. You can also look at the aftermath sections of other flights.

Sometimes, a human is to blame and there's no getting around that. This doesn't change their goal.

The difference is the approach — they look for the cause and sometimes the cause is the blame.

When you only look for the blame, you tend to be satisfied once you reach that goal and might ignore the cause.

NTSB, i think, no one takes the blame. For example, if the error is something like "Mechanic didn't tighten bolt to appropriate torque."

So, what's wrong? maybe they forgot and need a checklist item? Maybe the reading on the wrench should be recorded in the log? should there be a second person that verifies?

They know they ask a lot of people, and it has to be right, every time. People get sick, tired, distracted, whatever. we're people. People are the least reliable part of the system.

I think blame only falls to a person when they've lied. Falsified a log, claimed to do something they didn't etc.

That's the thing. In the Air Force (at least)- there is no thought of cost/benefit analysis. A single machine fails once because a bolt wasn't torqued and causes $5000 of damage ... So they add the checklist item, and the second person, and an extra training item, and a log record that has to be maintained. The list of special rules and required documentation only ever gets longer. Eventually, you spend all your time on the checklists and maintaining the documentation, and none on actually doing whatever procedure you were originally messing with that bolt for.

As someone who was a mechanic in the Army, I feel that checklists more often helped then harmed. Many mechanical problems we saw in the shop were easily attributable to an operator skipping a step on their PMCS. Doing something relatively dangerous or confusing could be error prone, especially for people who haven't done it much, and a checklist can help ensure the safety of everyone in the shop. A good example is running an engine indoors. Before you did it, there were a serious of steps you had to walk through before you turned it on, that reduced people getting sick from carbon monoxide quite a bit.

"The Checklist Manifesto" is an -excellent- read on the helpfulness of checklists in preventing problems and mistakes (primarily from a surgeon and medical viewpoint but he covers airlines as well.)

http://atulgawande.com/book/the-checklist-manifesto/

As a submarine fire control tech, I always thought it was cumbersome to have three full size binders open in my lap during weapon firing drills, casualty drills, everything except calm open water transit. But flipping those pages and grease pencilling things even while in the hot of prepping weapons to leave the tube avoided a LOT of "hurry up and whoops!" mistakes. Sometimes crufty stuff needs a review and rewrite but, n the whole, I'd rather know what happen wrong the previous times and avoid it myself.

This kinda contradicts the idea further up that too much attention is paid to process, at the detriment of, for lack of a better term, "skill" (or "personal responsibility")

I think the focus on process can be terribly annoying, because it's so much easier to say "Bob fell asleep at the machine" than diving into all the events that led up to Bob falling asleep. Note that both can be true or, more accurately, the process problems actually need the statement "bob fell asleep" to be true to make sense.

The idea to prioritise processes is that it's repeatable. Individual behaviour isn't within your control, except for the processes that hired somebody, educated them, defined their tasks, and created the environment in which they perform these tasks.

In a small team, or family, or group of friends, it's perfectly fine to dock Bob's allowance for falling asleep. And the instinct to exact revenge, or punish people is strong, because those instincts are the result of evolution and norms of society, both of which until recently only knew small groups where everyone knew everybody. That's why it takes a lot of discipline to act against these instincts, and obviously, as you said, because focussing on the process may also uncover others who failed, and it is more tedious.

People get frustrated with bureaucracy. Sometimes they're obviously right. But the idea that all bureaucracy is wasteful, or (equally common) that governments have any particular talent for wasteful bureaucracy is somewhat misguided. Because there aren't many examples for organising teams of sometimes hundreds of thousands of people to work on shared goals without a wasteful bureaucracy, and governments and the private sector tend not to differ that much.

I've seen one interesting example of a different structure for organising a large number of people: capitalism. It arguably works, being excellent at delegating authority to exactly the right person for any possible decision. But I believe even that example isn't convincing, if you start considering all the "waste" that capitalism hides in plain sight: advertisement, competing efforts doubling work, the complete financial sector, non-monetary losses due to financial hardship, the losses from unemployment being essentially wasted potential etc.

But unlike the NTSB, the military still routinely blames "pilot error" to cover up problems with terrible aircraft designs.

http://www.military.com/daily-news/2016/01/29/billows-of-dus...

Not accepting "shit happens" makes sense in aviation, and you're right about that

But taking out decision control and relying on automation has had its problems.

I think it's less about outside regulators than organizations/individuals optimizing to cover their own asses. I assure you, I'm not in the "gov'ment regulators ruin everything" camp.

> I think it's less about outside regulators than organizations/individuals optimizing to cover their own asses. I assure you, I'm not in the "gov'ment regulators ruin everything" camp.

The problem being that the ass-covering is a predictable response to known stimuli.

What do you propose to do to get them to stop doing that?