PPRuNe Forums - View Single Post - Near miss with 5 airliners waiting for T/O on taxiway "C" in SFO!
Old 24th Aug 2017, 00:27
  #979 (permalink)  
peekay4
 
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I can't see that the AC759 aviators are being portrayed or defended here as having done nothing wrong.
When we talk about punishment, we need to look at the bigger picture, not just this specific instance -- because punishment for operational mistakes sets a precedent regardless if others are supportive of the pilots or not.

Just culture is becoming the predominant safety culture, at least in North America (I can't really speak about elsewhere.) It's not just about pilots, but in all safety critical fields, including all forms of transportation (under the NTSB, Canadian TSB, etc.), nuclear safety (see IAEA's stance on open reporting of errors), medicine, etc.

In fact one of the most notable quotations about just culture was made by a physician:

The single greatest impediment to error prevention in the medical industry is
“that we punish people for making mistakes.”

-- Dr. Lucian Leape
Harvard School of Public Health
Testimony before US Congress.
A culture of safety must be based on trust. Pilots are human beings asked to make real-time, split-second decisions. Mistakes will happen. The solution is not punishment but to improve the system as a whole.

Some posters here (ahem) seem to be of the opinion that because many planes land successfully at SFO, that means nothing can be learned and nothing needs to be improved. This type of thinking is very dangerous.

Aviation is very safe because we are continuously learning and improving. Once we start blaming, trust will be lost, and the consequences will be severe.
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