seagull
Well-Known Member
Finding fault goes a long ways back in our Western culture. We want to find someone to blame, and that person is normally the last person to have had an opportunity (however reasonable) to avert the event. The position being made is very much in accordance with our legal system, and the system our military currently uses. Take the statement:
"Intent is not a necessary component of negligence. There are lawyers on this forum that can correct me if I'm wrong but I understand that "due care" is a common legal test for negligence. The Comair crew wasn't merely at fault, they were negligent.
Any pilot can make mistakes in judgement or execution, that is well understood. At a certain point, the threshold of negligence is reached. Often negligence is the result of an accumulation of mistakes."
The problem here is that the metric being used to determine if "due care" occurred is based on people who are using hindsight bias to make that determination. It is very easy to see the "obvious" issues when you know the outcome, however there is an extensive body of research that shows that those same people casting stones, when provided with the information that the person had at the time, and associated distractions, would likely make the same error. It is just very difficult to avoid hindsight bias. That is where the idea of "just culture" came from.
Assigning blame does nothing to get to the real issues that led to the accident, nor will it prevent a similar event from happening in the future. It might make you feel better by (erroneously) making you believe that it would not have happened to YOU because YOU are better than that (this is where the entire 'blame' culture really comes from, by the way), but it will not prevent another accident. Hammering the individual for missing something that was missed due to normal human brain functioning does nothing but make a few people feel better about themselves and allow the "system" to get away with not fixing the root problem. Typically, and organization that is using the approach you are talking about has a reaction that essentially tells all the front line operators that they "need to pay more attention to detail". While there is no harm in working on ourselves, these accidents are far more complex than this, and it really does nothing to prevent a future accident if a significant number of people, faced with the same distractions and information, would have made the same error. All we are doing is yelling for people to "stop it". In fact, a few years ago I was involved in the creation of safety video that discussed this exact issue, and one of the clips we used from was from the following video. Watch it and tell me how effective you think it is, because this is essentially what stating that an accident is individuals fault for inattention so everyone else "just be careful out there" is really doing:
"Intent is not a necessary component of negligence. There are lawyers on this forum that can correct me if I'm wrong but I understand that "due care" is a common legal test for negligence. The Comair crew wasn't merely at fault, they were negligent.
Any pilot can make mistakes in judgement or execution, that is well understood. At a certain point, the threshold of negligence is reached. Often negligence is the result of an accumulation of mistakes."
The problem here is that the metric being used to determine if "due care" occurred is based on people who are using hindsight bias to make that determination. It is very easy to see the "obvious" issues when you know the outcome, however there is an extensive body of research that shows that those same people casting stones, when provided with the information that the person had at the time, and associated distractions, would likely make the same error. It is just very difficult to avoid hindsight bias. That is where the idea of "just culture" came from.
Assigning blame does nothing to get to the real issues that led to the accident, nor will it prevent a similar event from happening in the future. It might make you feel better by (erroneously) making you believe that it would not have happened to YOU because YOU are better than that (this is where the entire 'blame' culture really comes from, by the way), but it will not prevent another accident. Hammering the individual for missing something that was missed due to normal human brain functioning does nothing but make a few people feel better about themselves and allow the "system" to get away with not fixing the root problem. Typically, and organization that is using the approach you are talking about has a reaction that essentially tells all the front line operators that they "need to pay more attention to detail". While there is no harm in working on ourselves, these accidents are far more complex than this, and it really does nothing to prevent a future accident if a significant number of people, faced with the same distractions and information, would have made the same error. All we are doing is yelling for people to "stop it". In fact, a few years ago I was involved in the creation of safety video that discussed this exact issue, and one of the clips we used from was from the following video. Watch it and tell me how effective you think it is, because this is essentially what stating that an accident is individuals fault for inattention so everyone else "just be careful out there" is really doing:
Really needed Wolf Blitzer aboard......
