Just Culture: Why is Jailing Pilots a surprise?

Does not the person in charge of any vessel or organization bear some legal responsibility? If so, why would anyone be surprised to see a pilot jailed following an accident? Are we really just seeing the terribly weak legal profession just beginning to realize how much work has gone undone in the past 70 years.

If in an accident, lives are lost and property is destroyed, why wouldn’t victims, survivors and claimants seek some form of compensation?

Is it really the accident investigation profession which has been dropping the ball all these years? Has ICAO really taken all the action that it could to actually promote safety and promote learning from investigations?
Or has the case really been made year after year that it is the pilots who made the errors and that is all the blame that we need to know about?

So finally everyone is reading these atrociously poorly prepared and written accident reports and noting what was written so often.

For years airlines, the FAA and NTSB has been laying all blame on pilots, often those deceased in the mishap, and directing attention away from ATC, manufacturers, the weather guessers, airport operators, and everyone else. So here we are in 2011, surprised and complaining.

Yet even as we write this blog, the BEA has issued a scathing reproach of the AF447 pilots who could not decipher the cryptic puzzle presented before them, struggled to save their own lives for several minutes before perishing. Nowhere in the report is any mention made of the responsibility of the dispatch office to advise of foul weather, of the manufacturer to sell good equipment, of the airline to verify that the equipment works, of ICAO and other agencies to keep updating all technology for the benefit of the flight crew. A passenger sitting in row 24 on that airbus could have accessed the internet and obtained the most up to the minute satellite pix, but the flight crew had on board pix probably over 4 hours old.

How inaccurate a weather data process could anyone ever invent? Make a copy of the last satellite shot an hour before brief time, have it ready for the crew who show up an hour and a half before take off and give them one hour old data. By the time they take the runway, the data is 2 1/2 hours old. At three hours into the flight the data is 5 1/2 old.
But wait, isn’t the entire life cycle of convective weather defined as a matter of 30-45 minutes, may be an hour tops? Moreover, doesn’t convective weather around the tropics often build at 4000 to 6000 feet per minute?

So how could 4-5 hour old weather ever be considered accurate or useful data for safety purposes? Why wouldn’t the airline and their dispatch office know this? Why would the official weather forecasters not offer more accurate weather data, some form or method of updating that sat pix in flight to the flight crew?

Oh yes the passenger in 24E has the latest sat shot on his PC.

So I can easily see why ICAO and BEA and everyone else are so determined to blame the pilots and by that process, not give a second’s care about what might happen to passengers tomorrow who might be in similar jeopardy.

Do you not think that the same mishap cannot happen tomorrow? Think harder. It can and it most likely will.

Just Culture proposes the idea that when the injury and loss of people, the damage and destruction of property is the result of a commercial aviation mishap, that all charges of criminality be suspended so that a safety investigation of the mishap can be completed without interference. My suggestion is that the safety investigation and the investigations to determine who was at fault for the losses and who pays for the losses proceed simultaneously.  Real evidence can be shared but evidence based on crew and other witness testimony should be determined solely by the board doing that investigation. Each board can and therefore should gather their own testimony evidence.

In the past, aircraft mishap boards have taken real evidence away from the public, which I do not believe is right. Additionally, they have taken years, 2-3 and more years to come out with any kind of useful reports, in essence failing to do the safety task of a quick safety hazard identification.

So now we find ourselves in a position where parties want recompense and no longer are willing to wait 8-10 years. No surprise that pilots are being jailed when an aviation mishap occurs where people are hurt and property is damaged. Just Culture is a good idea and I support it. But an even better idea is to prevent mishaps so that a flight never experiences a mishap and the lawyers are left with nothing to do.

Captain Miller with US Supreme Court Justice Sandra Day OConnor

About Paul Miller

Captain Paul Miller has developed a unique approach to aviation safety by forecasting safety hazards. Yes, that is right, forecasting safety hazards. Most people think of safety as a study of what has already gone wrong. But SafetyForecast looks forward in time at factors that will negatively impact your business in the future. Then using this unique and very powerful forecasting tool, you will be able to develop a unique Safety Plan. That is right, a Safety Plan. Your tailored Safety Plan will reduce losses of personnel and property to well below your most extraordinary expectations. That is our guarantee. No other safety consultant uses this method and no method has ever achieved the superior results by driving the mishap rate towards zero in such a short time. SafetyForecast modest consulting fees will be recovered by your business in a short time by the reduction of just the financial and legal losses alone, losses that you do not often think about due to mishaps. No other consultant will provide a unique Safety Plan that will make your company prosper by saving lives and injuries. Additionally your company will prosper by reducing the damage and destruction of property. Try SafetyForecast and you will see for yourself how well the Safety Plan works.
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