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Comment by wdewind | Hacker News Reader

The way around blaming them is that it has a horrible systemic effect to do so. In the future pilots are less likely to admit fault, less likely to provide details in investigations and so the organization has less data to learn with.

Instead look at what happened and say "if things had been different this couldn't have happened" and then make those things a reality. Maybe the answer is putting a sticker with metric/imperial conversion on the tank or something, so pilots aren't confused when checking with dipstick.

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> The way around blaming them is that it has a horrible systemic effect to do so.

That's why it's a good idea in complex systems to pre-assign to each requirement a responsible party. Otherwise, you could just use the "systemic effect" argument to either blame every party or no party in the system, neither of which is very useful.

The fuel requirement was pre-assigned (for every other model of plane in the Air Canada fleet) to the flight engineer. Who that requirement was assigned to for this one model of plane wasn't really clear in the article.

It was never explicitly said. The plane used to have a 3-person crew and had moved to a 2-person crew (missing the flight engineer). This left the check unassigned. It is mentioned in the 2nd paragraph under the Investigation header.

You misunderstand my point, I think.

If you are running an organization that deals with a lot of complexity (airlines, web systems etc.), it's generally not a good idea to blame anyone but the system. If you look at everything systemically, then the organization continually learns. You have to trust the people in the system to be coming to work in good faith, if you can't do that you have other issues.

I can see where it looks that way, but I don't think the effects are like that in practice. From the Wikipedia page, it appears that the career effects of this for the pilots involved were fairly minor, given the mitigating circumstances.

And I'd argue that's a Good Thing.

I don't really follow. How are you going to recommend changes which help the pilots make correct decisions if you don't say that this event occurred because these pilots didn't make a correct decision?

You trust that the pilots made the best decision they could given the data they had, and you find a way to give them better data next time. If they took a known risk, you ask why they thought it was ok to take that risk.

If you think they were truly acting in bad faith, you have other issues.

"The pilots were at fault" does not mean the same thing as "the pilots were acting in bad faith", not even remotely.

Sorry, maybe I wasn't being clear. I don't think they are the same thing, my point is more that if you think someone is acting in bad faith you should fire them, but assuming they aren't, you shouldn't assign the fault to them, because then the only solution is "just do better next time." The organization learns nothing if you assume the pilot is at fault. The entire point here is that the pilot is not at fault, which leaves the door open to fixing the system. It's all about enabling organizational learning.

That makes no sense. Assigning fault to the pilot could mean that your training is inadequate, or that your rules for rest or drugs aren't sufficient, or that they need to be more explicitly empowered to resist external schedule or financial pressures, or any number of other things.

There's a wide range of reasonable "it's the pilot's fault" judgments which don't involve firing them or just shrugging your shoulders and saying "do better".

I guess maybe this is just an issue of semantics. I don't view the pilot being at fault if the training is inadequate, I view the training as being at fault.

Two sides of the same coin. If the engine explodes due to a manufacturing defect, is it the engine's fault or the factory's fault? Both.

What really matters is what the fault implies. Finding the pilot to be at fault does not imply that people just give up on figuring out a fix.

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