1. If you are investigating an aviation mishap and asking the question, “Who was at fault and who pays,” then you are doing a legal investigation.
2. If you are investigating an aviation mishap and asking the questions, “How did this happen and how can we prevent a recurrence?” then you are doing a safety investigation.
3. In either case, what is written on the door of your office, the door of your truck or car, the name tag you wear or the title of your agency is not as relevant as which set of these questions begins your investigation.
4. If the title of your agency says mishap investigation, but the purpose of your investigation is to find fault, then you are conducting a legal investigation and it is very likely that the safety purpose will go unfulfilled. The Safety Purpose is to ask, “How did this happen and how can we prevent a recurrence?”
5. A legal investigation is designed to determine, “Who was at fault and who pays?” In many, perhaps most ways, the legal investigation looks backwards.
6.The safety investigation however only works if it looks forward, because the investigators have to determine how to prevent a recurrence. How often do you think mishap safety investigators get this right?
7.Safety investigations are only complete when the cause is found and recommended procedure and training changes are determined that, had they been in place, would have prevented this mishap from occurring. Therefore, Probable Cause determination is not good enough, because you will not know what to fix to prevent a recurrence. You have to know the cause or causes, so that if they are indeed valid, you can then develop a recommendation for corrective action, that if all were to follow in the future, and had been in place before the mishap, would ensure that this mishap never happened and would never happens again.
If for example, no one at the Air France Dispatch Office is tasked with flight following, and looking ahead of the flight path of a dispatched flight to see if any weather hazard is in the path of a dispatched flight, and then tasked with coordinating a new and safer path diverting around the hazardous weather, and coordinating that path with flight planning, metro, ATC and the crew, then I would expect a 100% probability that this mishap will occur again, at AF and at every other airline that fails to complete the tasking required to ensure safety of its flights and its embarked passengers.
2 thoughts on “Who Was at Fault & Who Pays versus How Did This Happen & How Can We Prevent a Recurrence”
For safety purposes, it is absolutely necessary to find out what happened and how can we keep this from happening again? I would reiterate this for two reasons: first many so called safety boards do nothing other than find out who they believe was at fault and allow a court to determine who pays for the damages and injuries. That is not at all however a safety investigation. I repeat, that is not a safety investigation. People conducting this style investigation should be given no more access to the crash site, witnesses and survivors than any other interested party. The use of the term "party," which is a legal term, means that the board is conducting a legal investigation. The board in so doing is only answering the question of "who was at fault and who pays?"The board therefore never completes the primary task which is finding out "what went wrong" and "how can we keep this event from happening again?"Secondly, failure by boards to complete the safety function by accident boards, has led to the most common type of commercial airline mishap, that is, the repeat of the previous mishap again and again.Any statistic in use today will bear that out with repeat after repeat events of previous mishaps.Yet every mishap is preventable if we determine what went wrong and take steps to prevent it from happening again.
A great disservice occurs when boards operating under the legal umbrella of safety actually and in fact represent the interests of parties involved and not necessarily those of the traveling public. Proof? Look at the continual repeating of similar mishaps, while at no time is government regulators held accountable or forced, influenced or in any way required to improve regulations, the very regulations complied with at the time of take off.