Safety Mishap Investigations are intended to prevent the same mishap from ever happening again, from ever reoccurring. But what often really does go on during the investigations conducted by NTSB, FAA, BEA, ATSB and other national boards around the world?
Here is my opinion, here is a look into what often goes on in the name of a Safety Investigation:
Rule One: Protect Those in Power, Those with Money and Influence. Prevent those without Power, Money and Influence from gaining control of any part of the "Safety Investigation" by claiming that the "Common Good of the Traveling Public is at Risk!" Then as the board is claiming this as the reason or charter under which the board is operating and all other reasons, charters or claims to be secondary, self serving, sensationalism, self interest or distractions, proceed on protecting the powerful, moneyed and influential, the board conducts a legal based investigation in preparation for going to court. The questions of "What Happened" and "How do we keep this event from ever happening again?" are lost in the rush to "Who was at fault?" and "Who pays?"
Rule Two: Attempt to find persons and parties without Power, Money and Influence and try to legally blame them for a major element of the mishap. Avoid finding the actual cause of the mishap. This way you will not be tasked with the obvious, that is, finding actions to prevent the mishap's recurrence the next day, next flight or next operation. This way nothing needs to be fixed and therefore no one is held accountable for not fixing the hazard sooner. Remember that a cause has to be pretty certain or it is not really a cause; rather it is just a coincidental event. But legally often just coincidental event reasoning is sufficient to assign blame.
Rule Three: Generate "Legal Uncertainty" using the term "Probable Cause" [the greatest oxymoron in this field] so that those with Power, Money and Influence have enough legal smoke screen to hide behind. Remember legally that "reasonable doubt" is enough to protect against guilt in a death case and that the generation of Uncertainty will provide that doubt. Forget all about finding causes as the board should be doing. Come up with all sorts of coincidental events about which the board is not happy and make a big deal about how fixing them is so important. Remember to avoid at all costs finding a cause, unless under Rule Two you can find someone who perished.
Rule Four: Turn all the losses of property over to the lawyers to pay compensation as assigned by courts or separate agreements.
Rule Five: Lawyers have ways of evaluating the worth of each human life lost, through a centuries old calculus of case law, gender, net worth, earning power and other accounting practices. Again, turn the loss of life litigation over to the lawyers to hash out who gets paid and how much, there by avoiding having to deal with the human emotional tragedy of loss of life, lives belonging by the way to the "Traveling Public."
Rule Six: At some very distant point in time down the calendar, maybe at three, five, ten or twenty years, enact some attempts, often outdated by now, at fixing what was wrong in the first place, THE CAUSE(S), that everyone outside the "Parties To The Investigation" and those "Parties To the Investigation" without Power, Money or Influence thought needed to be fixed and demanded such during the investigation. The distancing in time, after the claims litigation is completed allows this process to move forward without incurring new compensation claims. It also allows the human emotional tragedy from having to ever enter into the Mishap Safety Investigation process. Turn that responsibility over to the Grief Counselors who deal with the "inevitability of tragic human loss" in everyday life and this keeps it apart from and unrelated to the investigation for convenience of the boards.
Well, that about sums it up, no?
One question though, why is there no attempt to find out what went wrong quickly so that if the condition exists in other planes, operations, airports, flight crew or other elements of the system, it could be fixed before another tragedy occurs?
Could this be why in commercial aviation we observe the essentially "same disaster" or at least, the same type of disaster reoccurring over and over again? Is the fact that the boards take years to come out with any reports not totally contrary to their basic safety charter and in fact a contributory reason that we take so long to learn the lessons of these mishaps if we ever learn them at all? Isn't this contrary to the reasoning that every living adult tries to learn in their early years to make life successful? Why is there such a great distance in the thinking and reasoning of every living adult and the thinking and reasoning often of the major aviation safety mishap investigation boards?
Shouldn't the purpose of a Safety Investigation be to "find out what went wrong and take action to ensure that this event never happens again?" Isn't that what all of us do in life to keep from making the same mistake twice? Why wouldn't that same reasoning apply when we are talking about "Flying the Traveling Public Around the World in Our Commercial Aviation system?"
Why have we all failed so miserably to make commercial aviation safer? Why have the operators and the safety people and the owners and the regulators failed to make commercial aviation a form of transportation with a mishap rate either at or very near zero? Why do some airlines, why do some airfields, why do some aircraft, why do some flight crew members operate for years mishap free, often for entire careers? Is it just chance as the lawyers would have us believe? Does that even make any logical sense? Have we ever asked an airline, a manufacturer, an airport operator or a flight crew member who has completed a career mishap free for any suggestions? If so, have we ever heeded the same?
Or are we just stuck on Rules One through Six?
Welp, look back at Rules One through Six above and you may find your answer. Are willing to defer power to the powerful and influence to the influential? Do we then will find the mishap rate continuing to hover where it is now or worse yet spike up at times, in places, with aircraft, with people? Will we all continue to spin the wheel and take our chances that the next tragedy will happen to "someone else?"
Maybe, just maybe, we could chart a different course? Could we start to do actual Mishap Safety Investigations? In many cases now what the NTSB, FAA, BEA, ATSB and other national boards do now is to protect the powerful, moneyed and influential, while at the same time fail to achieve their own chartered purpose of Safety.
When will the leadership of national mishap investigation board finally begin to do what they were established to do? Is there any leader who actually knows what they are supposed to be doing?
If so, their voices have yet to be heard.
This of course is my opinion.
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