Accident analysis is the business of identifying mishap causes and recommending actions to prevent a repeat mishap.
Who's to blame doesn't matter.
The laying of blame, extraction of justice, punishment, liability, etc - all these are the business of the courts (and to satisfy our inner need for balance and justice in the universe), but they don't really address mishap prevention. Mishap prevention involves actions.
Example:
Lets say the causes of a mishap are all actions taken by a boat's captain.
Mishap analysis would identify those actions as causes, and recommend other actions that would prevent (or greatly reduce the chance of) the mishap in the future. Nothing about liability, fault, blame, punishment etc would be addressed in the mishap analysis because those are not actions that would prevent the mishap.
Example: "The boat didn't have enough fuel on board to conduct a search." might be identified as a cause of a mishap, and mishap analysis would recommend "that a boat always carry enough fuel to conduct a search" on every dive. Why the boat didn't have enough fuel, who made the decision to carry too little fuel, whose fault it is that the boat had too little fuel, etc, are all questions for regulators and courts, not mishap analysis. And it may be that there's no blame anyway - it could be that a new standard needs to be set because this mishap revealed a flaw in the current standard.
The general theme of mishap analysis is that all mishaps are preventable, even when no one is at fault. For example, all diving mishaps are preventable by not diving in the first place.
Mishap analysis doesn't waste time asking "what was he thinking?" either, but rather asks "what did he do?" We can agonize all day long about why Joe didn't ditch his weights when ditching his weights would have saved him, but it doesn't really matter. The action that will prevent a repeat of Joe's mishap is "ditch weights."
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What we're trying to do in the A&I forum is to provide a forum for a Safety type analysis of mishaps; to identify actions that lead to mishaps and actions that can prevent mishaps. The mishap analysis mindset is difficult for those who lack formal training in it, as our natural tendencies are to find out who or what to blame and seek justice.
Just remember that justice isn't going to prevent future mishaps. It is changes in behavior that prevents recurrence of mishaps.
Rick
Who's to blame doesn't matter.
The laying of blame, extraction of justice, punishment, liability, etc - all these are the business of the courts (and to satisfy our inner need for balance and justice in the universe), but they don't really address mishap prevention. Mishap prevention involves actions.
Example:
Lets say the causes of a mishap are all actions taken by a boat's captain.
Mishap analysis would identify those actions as causes, and recommend other actions that would prevent (or greatly reduce the chance of) the mishap in the future. Nothing about liability, fault, blame, punishment etc would be addressed in the mishap analysis because those are not actions that would prevent the mishap.
Example: "The boat didn't have enough fuel on board to conduct a search." might be identified as a cause of a mishap, and mishap analysis would recommend "that a boat always carry enough fuel to conduct a search" on every dive. Why the boat didn't have enough fuel, who made the decision to carry too little fuel, whose fault it is that the boat had too little fuel, etc, are all questions for regulators and courts, not mishap analysis. And it may be that there's no blame anyway - it could be that a new standard needs to be set because this mishap revealed a flaw in the current standard.
The general theme of mishap analysis is that all mishaps are preventable, even when no one is at fault. For example, all diving mishaps are preventable by not diving in the first place.
Mishap analysis doesn't waste time asking "what was he thinking?" either, but rather asks "what did he do?" We can agonize all day long about why Joe didn't ditch his weights when ditching his weights would have saved him, but it doesn't really matter. The action that will prevent a repeat of Joe's mishap is "ditch weights."
--
What we're trying to do in the A&I forum is to provide a forum for a Safety type analysis of mishaps; to identify actions that lead to mishaps and actions that can prevent mishaps. The mishap analysis mindset is difficult for those who lack formal training in it, as our natural tendencies are to find out who or what to blame and seek justice.
Just remember that justice isn't going to prevent future mishaps. It is changes in behavior that prevents recurrence of mishaps.
Rick
