I don't think I'm being controversial if I say that we are all disappointed when we hear that there has been accident where people have been killed or injured. Unfortunately, the natural reaction of the public is as follows:
- Something went wrong
- Someone must be at fault
- Someone must now be punished
- That will stop it happening again
- Only then will be safe.
It is a simple creed and meets people's basic need to get rid of nasty things. The public doesn't like open ends, threats, possible unpleasant outcomes. Furthermore, they are totally satisfied that simply punishing someone will prevent reoccurrence.
Unfortunately, lawyers and the justice system like this approach as well. If someone (anyone) can be held responsible for an event, the "system" can say it has worked. So who and what gets the blame? The easiest path to take is blame the person controlling the thing that caused the damage. If you can't get to the person, get to the thing and if you can't get that, get to those who made the "thing". As far as they are concerned this process is elegantly simple.
But this short sighted, naive approach adds nothing to safety. Accidents are little more than unintended and unexpected outcomes. They are typically the culmination of a long string of factors and events initiated maybe many years before hand. Examples of this are the working practices responsible for the Clapham Junction rail crash, signal design and route training giving rise to the Ladbroke Grove accident, the door design, ship and operating practices on the Spirit of Free Enterprise. No one person, thing or practice caused any of these events. Each was the result of many factors. Therefore holding just one person or thing responsible can not be the right thing to do. But this is inelegant for the legal profession and has too many open ends for the public. The police and public prosecutors don't like it either. They appear to live in a binary world. So if they can prove the most minor of transgressions within a complicated chain of events, they can and will prosecute. Couple that with a good prosecutor and a weak defence and you are now 100% guilty.
Natural justice requires the following:
- An independent judge
- Assessment by your peers
- A right to see and question the evidence against you
- The right of appeal
On the face of it you may say the above replicates the legal criminal system. Well to a point it does. But one of the problems is the selection of your peers. It should be nurses who assess nurses, doctors who assess doctors and train drivers who... Only these people have an insight into the nitty, gritty details of the job. No matter how intelligent, quick witted or open minded members of the public are, they will never fully understand the tasks of a mariner, coach driver or doctor.
Another is the presentation of the evidence. Because the current jury system uses members of the public, the evidence presented has to be pre-digested for them. It's then spoon fed. And this is where the "experts" come in. They will not be independent. They are are there to help one side of the action prove its point. They are not there to be objective and certainly not present to prevent reoccurrence.
In this case I believe releasing CVR data will be a mistake because it will not be assessed by people who understand what is in (or not in) the data. We can see examples of this when data is released to the media. So called experts (like that clown from Janes) tell us what happened from a position of total ignorance. They are unable to set the evidence they have against any context because of their lack of real knowledge of the subject and incomplete information. Unfortunately though, the messages behind their opinions are generally so simple they satisfy the public's need for a simple closure. Releasing FDR data as well might reduce the magnitude of the mistake but only because it allows the defence to make a better case.
A safer world is a reasonable goal. This can only come about by a mixture of safer equipment, practices, training and environment. All of this has to be built on the foundation of what currently exists - an extant, imperfect world. At the same time, we also have to accept that 100% safety is totally un-achievable. And this might not be acceptable to the public, even though this is a fact of life. As I said before, the public want certainty and find "maybe's" and "possibly's" hard to live with.
Justice? Well it's legal but it won't add to our safety. Also, our so called justice systems don't require us to contribute to our prosecution. Furthermore, because our actions are not assessed by our peers only a fool would willingly contribute information that may be used against themselves. Yet to make our world a safer place we have to have knowledge and experience of past events. Close this source of information and our future would will be built upon a blinkered vision of the past. It is also a great shame that our compensation system is based on blame determined by the justice system.
Not once have I said that that pilots must not be prosecuted. That is because I believe that nobody should have their professional conduct discussed in a court of law. This is because they are not capable of doing the job properly. Criminal prosecutions compromise our future safety. Only when professional conduct is properly assessed outside the current legal system will we be able to make some real, worthwhile improvements in safety. And we can fix the wretched compo system while we are at it.
PM