> “But recall that this chapter is about layering, units, hierarchies, fractal structure, and the difference between the interest of a unit and those of its subunits. So it is often the mistakes of others that benefit the rest of us—and, sadly, not them. We saw that stressors are information, in the right context. For the antifragile, harm from errors should be less than the benefits. We are talking about some, not all, errors, of course; those that do not destroy a system help prevent larger calamities. The engineer and historian of engineering Henry Petroski presents a very elegant point. Had the Titanic not had that famous accident, as fatal as it was, we would have kept building larger and larger ocean liners and the next disaster would have been even more tragic. So the people who perished were sacrificed for the greater good; they unarguably saved more lives than were lost. The story of the Titanic illustrates the difference between gains for the system and harm to some of its individual parts.
The same can be said of the debacle of Fukushima: one can safely say that it made us aware of the problem with nuclear reactors (and small probabilities) and prevented larger catastrophes. (Note that the errors of naive stress testing and reliance on risk models were quite obvious at the time; as with the economic crisis, nobody wanted to listen.)”
Another interesting argument along the same lines is that if we hadn't bombed Hiroshima and Nagasaki, there would have been no reason for Truman to stop MacArthur from using bombs a hundred times worse in the Korean conflict.
It's a sobering thought regardless of one's opinion on the atomic bombings in Japan. The lesson was going to be learned one way or the other, and arguably humanity got off easy.
In "Fate is the Hunter", Gann lamented that the airlines had to be forced by regulation to adopt as straightforward a safety measure as the rotating beacon (flashing red light), a change that pilots of the day had to lobby for.
I worked in the business and I'd never heard of it until a hardware engineer (with WDC) told me I had to read it. He was right.
It's a nail-biting, seat-of-the-pants diary of the author's career during the early days of commercial aviation. So good.
(me: aircraft dispatcher in my previous life)
In that frame suddenly the driver stops saying they weren't too drunk to drive and says next time they'll take a cab. The policeman stops saying the suspect "wasn't complying" and agrees that they need training on how to de-escalate situations.
Medicine does have tools for this, the M&M conference (medics discussing why somebody died or had a bad outcome and how to do better next time) is under-used.
Humans are fallible, blaming a specific human makes us feel better but does not prevent the same thing happening again.
> The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the lowspeed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s
failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.
 The report would be hearsay in a criminal case and admissible only if the government demonstrates an exception to the rule against hearsay evidence.
The NTSB tries to determine "Probably cause". That's a far cry from assigning blame. In particular, on every NTSB report there's a big box specifically saying (my emphasis):
> The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties ... and are not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4. Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations.
Furthermore, to "ensure that Safety Board investigations focus only on improving transportation safety, the Board's analysis of factual information and its determination of probable cause cannot be entered as evidence in a court of law."