Responding to mistakes: How we can learn from air-crash investigations
There can be a lot to learn from the aviation industry, and more importantly how they respond to something going wrong. We can apply this how we respond to our own mistakes and what happens when a mistake causes everything to go to hell.
Aircraft are well known as being one of the safest forms of transportation and for good reason, and that isn't that air flight is just inherently safe, because the reality is that it isn't. Rather, much work has been done to make it so. And there is no more obvious demonstration of this then in the way the industry responds when something goes wrong. Anyone who has ever seen an episode of air-crash investigations would be well aware of how meticulous the process of investigating something going wrong is. Every action is analysed, every part inspected, every chip, dent, scratch and crack recorded. And only once all that is done, once they have a full picture of every detail involved and understand everything that happened do they give recommendations. Recommendations, not blame. Yes, they may assign fault, but it's not why they did all that.
There is a reason crashes are so rare. Every bolt, every screw, every wire and every part is tested to failure, over and over, and maintenance replaces them well before they reach that point. Each component is designed with tolerance to withstand far higher stress then it could ever receive. Any part that could fail is made with redundancy. Even the human element is made with redundancy, pilots always operate in pairs so that if one makes a mistake the other can catch it. The pilots are trained to repeat all instructions back to the tower so that even instructions include safe guards. And yet all of this can and has gone wrong. Even the most perfect safeguards can't account for everything, and especially multiple things going wrong in a row.
This is where the investigations and the recommendations come in. They identify every point of failure, everyone made by the pilots or failed component in the plane. They recommend increased tolerances, greater redundancy, modifications to training and anything else that could have prevented the accident. Because at the end of the day, no matter how hard you try, components will fail, humans will make mistake and situations which nobody predicted can arise for which there are no protocols in place. Generally serious accidents only happen when a chain of these events occur, rarely ever is there a single piece of the whole system at fault. Only by calmly analysing the whole chain can those be found and steps be taken to prevent them from happening again.
So you are probably thinking "what does this have to do with me? How can I learn from this?". Well basically the idea is; if you make a mistake and things go bad, don't get angry and blame yourself. Take a step back and look at the full chain of events that lead to it. Were there proper steps taken to prevent or mitigate this? Why did they fail? Were there external factors or actors that contributed? Did you making the mistake only cause things to go that way because it compounded other mistakes? Can you put systems in place to prevent this in future? Are there lessons to be learnt from this? Are you even the only one at fault? Or are you just blaming yourself for factors and other's actions which were out of your hands?
Like with aircraft, we all have procedures and safeties in place so that one thing going wrong doesn't cause something bad to happen. We might not even be aware of their existence, but they do exist. However, most of us never bother to look closely at them and analyse why they failed when something bad does happen, we just get mad at ourselves and point at the final mistake in the chain. Usually accompanied by some form of self degradation.
If instead, when something does go wrong, we carefully analyse every step in the chain, find every contributing factor, we can afford to be much kinder to ourselves. Instead of just getting mad, we can create a set of recommendations to ourselves to avoid it happening again. We can establish a set of personal safeguards which tell us "doing this thing or this event happening will lead to a negative outcome, we should act in this way to avoid that".
Sometimes a crash does come down to pure pilot error or the pilot ignoring those guidelines, but even then the recommendation is not "the pilot fucked up let's go home", it's a set of recommendations for stricter training and closer evaluation of pilots. The goal is to help prevent pilots making those errors again, not blame and punish them for making it in the first place. Likewise, our goal in this line of thinking and self evaluation is to remove the "I did bad, I'm just a useless idiot" step from the equation. Instead we replace it with a framework that lets you actually learn and improve from your mistake and to accept that often your mistake was just piece of a longer chain that was likely totally out of your hands.
And yes, "modern aviation is the safest form of transportation" only applies to planes, helicopters are actively trying to kill you at every moment and only prevented by a delicate balance of physics, engineering, pilots skill and brute force that can fail at any moment.
This post was inspired by a post from user json-derulo on Tumblr.