Originally Posted by
safetypee
Punishment, attribution, cause; or understanding from which to learn.
If we start with a viewpoint of the first three, then a person can be identified. The old view of safety, a natural self satisfying human reaction, often the basis of litigious judgement. Has been useful in improving safety, but only so far.
Alternatively seeking understanding, particularly in complex systems can provide insight to improve the processes of design, certification, and operations. Need for more systems thinking in very safe operations.
The real world is never a clear cut one or other extreme, thus it is important to consider our viewpoints, where are we starting from, our assumptions, what do we wish to find, how we frame our thoughts.
https://www.researchgate.net/profile...ication_detail
Am I correct, you want to introduce a kind of "just-culture" around this subject ?
If so, in principle, this sounds a good idea, though looking a little further into the Boeing case, I don't think, this MAX saga could be handled from a just-culture perspective. The reason for this is, the mishap was a deliberate top-management action, in violation with the fundamental principle "Security is our first priority" (all signs are there, including the "hiding"/"lying" towards FAA and customers). The MAX MCAS failure was not an engineering accident, its happening was build into the organization of Boeing engineering, the compartmentalization. Once an action is deliberate and warnings have been issued that the action will fail, a just-culture approach is past its goals: "Learn from one's honest mistakes" and it becomes criminal.