No Man is an Island

I've been a bit out of the loop over the past couple of months as I try to get a handle on my new job and the (almost overwhelming) responsibility that goes along with it. But I can't ignore the action over at the Federal Senate's Rural and Regional Affairs and Transport References Committee's inquiry into Aviation Accident Investigations.

Before I comment, some disclaimers - I'm not going to comment on the particulars being discussed at the Senate hearings. While I worked with many of those involved, I never worked on anything associated with the accident event (before or after) but if I were to comment, it might look as though I have inside information, am bearing a grudge or just being an stirrer. I don't, I'm not and maybe just a little ;).

I do, however, want to comment on the philosophy surrounding some of the issues at hand.

The particulars of the situation on which, I would like to comment are, basically, that an accident occurred and the resulting investigation focussed on the operating crew. In the 15th February hearing, two comments by Senator Fawcett struck me as warranting further examination. They were:

One thing the committee wants to put on the table upfront is we accept the contention by CASA that there were errors made on behalf of the pilot in command of the flight. There seems to have been some concern raised that this inquiry is all about exonerating an individual and shifting blame elsewhere. That is not the case. We accept the fact that in the view of some it was even a violation is supposed to error. (p. 1)

With the concept of a systems approach, whereby not only the operator and the piloting command but also the regulator are key parts of the safety system... (p. 3)

For all the other problems we seem to be having in this scenario, we still seem to be stuck on the basics.

Part of a Complex System

Senator Fawcett's second quote there and numerous others throughout the course of the hearing shows that he is quite familiar with the concept of a safety system but he, and I think a large part of the industry, can't escape the concept of personal responsibility associated with criminal law.

The language of "exonerate" and "shift blame" suggests strongly that the old approach to investigations and safety improvement is still alive. We seem to have slid back into the days of pointing the finger at the front-line operator, stamping the label of "cause" upon them, punting them into touch, dusting our hands and declaring the world a safer place.

Okay, I'll admit that this could be a harsh analysis of what is possibly a "throw-away" line but the language could indicate a deep-seated belief in the very concepts we are supposed to have left behind. I'm also not singling out Senator Fawcett. I think we all fight these traditional ideas, conditioned within us since an early age. How many of us still use the word "cause" despite its often misleading level of direct influence and independence?

Exonerate, Exshmonerate; Blame, Shame.

It's a hard thing to let go of but, I think, we have to let go of the criminal view of personal responsibility when we are dealing with accidents in complex socio-technical systems, such as aviation. I'm just going to come out and say it:

No one, who participates in the aviation system, should ever go to jail, be fined or sanctioned as a criminal. Ever. Regardless of the error, violation, failing, mistake, slip, lapse, omission, commission, faux-pas, foul-up, whatever.

If we accept that aviation is indeed a system - a complex set of individuals, machines, procedures, tools, organisations - all working to achieve the objective of moving stuff from A to B - then no single part of that system can be singled out as having "failed".

As a system there are, or should be, feedback loops. Sub-systems for checking and re-checking. There should be self-correction. If one part has failed, more parts have failed; in fact, the whole system has failed.

If you are going to blame one, you need to blame all. Jail one, jail all. Fine one, fine all.

Whoa Warden, Don't Open that Door Yet

I am definitely not advocating some criminal reform agenda that would see society's jails shut-down and personal responsibility disappear. I am arguing for a clear distinction between how we view undesirable events within the aviation endeavour and in society at large. I don't think it is appropriate to look at the aviation industry as a sub-set of society and apply the same thinking.

The big differences between aviation and society are choice and intent. Pilots, ATC'ers, LAMEs, AROs and many others choose to be part of the aviation with the intent on achieving the industry's objective of moving stuff from here to there safely.

Society on the other hand is, really, all encompassing. By definition, we don't really have a choice to join. You could run off into the woods, build a log cabin and live as a hermit but you'd still be a part of society in the broadest sense and still, more importantly, be subject to various laws governing human relationships.

What to do with a broken part?

A while back the industry tried "no-blame" and it didn't work. I think it was because the concept suggested there would be no ramifications, no consequences to behaviour which contributed to undesirable outcomes.

And this, of course, is untenable. If the system experiences an undesirable state or outcome, it should be able to correct its performance.

The response was to abandon "no-blame" as going too far but I think the problem was that the concept of blame actually ceases to have any meaning within a safety system approach. Much like one cannot meaningfully discuss events "before" the big bang, because time began at the big bang.

So What's the Lesson?

The tiny lesson I'm trying to get at here is that we need to try harder to fully integrate the system approach into our thinking. It's not so much that we can't identify frontline operators as contributors to accidents but that there will (not might) be more to the story. Someone else, actually numerous people, will have contributed, in every case.

And in taking this approach, in identifying as many contributory factors as possible, the actions we take with respect to those people, tools, equipment, etc. will be and be perceived as appropriate. It will support actions like suspending a licence, grounding a fleet or withdrawing a certificate.

Without it, honing in on a frontline operator and booting them out of the system will never look justified regardless of how necessary it is.

PS - Criminal Offences Against Aviation

There should still be criminal offences relating to aviation. For example, morons who shine lasers at aircraft should be tried as criminals because they have not chosen to be part of the aviation system or intend on supporting its objective. Same goes those who wish to use civil aviation as a weapon. 

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