A Proven Alternative To Blame

I once saw a documentary about airplane accident investigations that illustrated an effective alternative to the counterproductive blame game that our System currently plays with crime. The subject of this particular episode was a mid-air incident that nearly cost the pilot his life, and much worse, but fortunately ended well (nobody suffered any permanent injuries). Regardless of the outcome, like all life threatening (and profit threatening) airline incidents, it was taken very seriously and became the focus of a major investigation by private investigators who work for the airlines, not the government.

Now, I emphasize here that the investigators work for the airlines, not the government, because this changes the primary goal of the investigation from pacifying the public to protecting profits, and as a result the string of resulting secondary goals change as well.

Government investigators must ultimately cater to public emotion, which motivates how people vote, and what opinions they hold about various public officials and issues. Because of this they are driven to find someone to blame, rather than a real cause of the problem. Blame, and the superficial cause that it represents, is the most expedient and simplest (i.e. least expensive) means of pacifying the simple mind of the masses.

But private investigators must typically answer to a small board of profit minded directors. They care almost nothing about who is to blame for the accident, they care only that the real cause be found so that steps can be taken to stop the same kind of accident from happening again. Why? Because they know that a repeat, and hence, preventable accident is far worse for profits than a new unavoidable one.

What happened was the windshield on a commercial passenger jet blew out of its frame by the internal cabin pressure as it reach attitude shortly after take off. As a consequence, the pilot was literally suck out of the plane and saved from certain death because his leg got caught on his seat belt strap, giving the co-pilot enough time to grab the pilot before he was blown away by the 500 mile per-hour wind. But, because of the wind, which pressed the captain's unconscious body back against the fuselage, the co-pilot couldn't pull the pilot back into the plane; not even with the navigator's help.

So, the co-pilot radioed in an emergency and quickly turned the plane around and landed it with the pilot still hanging outside the entire time.

The pilot survived, miraculously, and made a complete recovery. But everyone wanted to know how the hell a window just blows out of a plane like that. So the private investigators were called in.

As it turned out, the windshield had recently been replaced for some routine maintenance reason, and the wrong screws were used to bolt the window into its frame. And that's as far as any government investigators would have gotten. They would have blamed the mechanic who replaced the windshield for using the wrong screws, probably have him fired, fined, or maybe even criminally charged, and then act completely surprized the next time a window on another jet blows out in mid-flight.

But, the private investigators were only just getting started. They interviewed not just the mechanic who replaced the window, but also the tool room clerk, the other mechanics in the maintenance hanger, and looked at the design specifications of the plane, especially the windshield, and the maintenance procedures, in theory and practice. What they found out was that the screws that the mechanic used by mistake look almost exactly like the screws he was supposed to use. The only difference was that the wrong screws were just a few centimeters shorter. Maintenance procedure demanded that all the screws be replaced, which is why the old screws weren't used. Maintenance procedure also required that the mechanic verify that he has the correct parts by cross-checking the numbers with the tool room clerks records. But, in practice this was not done because it took too much time and the maintenance supervisors pressed the mechanics to rely on their experience and take short cuts.

So, in the final report to the money bags what do you think the investigators recommended? Fire the mechanic? Fire the tool clerk? Fire the maintenance supervisors? Sue the plane manufacturer and designers?

None of the above. Instead they thanked the mechanics for the information and for helping with the investigation, and made no suggestions than any actions be taken against anyone (i.e. they weren't interested in the blame game). They recommended that maintenance procedures be evaluated, and changed, so that part number confirmation was made practical and not time consuming for the mechanics. They also recommended that the mechanics be given more breaks in their work hours to reduce fatique and the urge to take short cuts.

As I recall, all of these changes were made; not just locally at that one maintenance hanger, but throughout the industry! The mechanic who made the mistake said later that he was always more careful than ever about making sure he had the right parts. By keeping him on as a mechanic, and allowing him to participate actively in the process of finding a solution, the airline not only kept an experienced and highly skilled mechanic, but they also got one who would remain hypervigilant for the rest of his career!

Perhaps there is something to be said after all for profit driven organizations as opposed to bureaucratic ones.

(J.D. 5-20-2014)