I can't be the only person here with an understanding of CRM?
Some basic principles.
(1) Somebody does something wrong.
(2a) They are then criticised or punished. Result, everybody else runs for cover, recriminations surround, nobody deals with the underlying problem.
(2b) They are asked to participate in finding the solution and preventing a recurrence. Most people muck in to help, the underlying problem gets tackled.
(3a) Somebody repeats the mistake, go back to (2a) again,
(3b) Everybody knows how to avoid the mistake, hopefully it doesn't happen again.
Public accusations and recriminations are really really unhelpful because although the punitive culture makes people try hard to not mess up, they don't resolve the underlying issues that ultimately will cause somebody, somewhere, to screw up.
Hence the well known phrase on the front of AAIB's website...
The purpose of the AAIB is:
To improve aviation safety by determining the causes of air accidents and serious incidents and making safety recommendations intended to prevent recurrence
...It is not to apportion blame or liability.
Keith Conradi, Chief Inspector
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