The ability to drop blame from the equation is a credit to the aviation industry and would drastically improve any team, organisation, or industry to adopt it.
When the conference LeadDev happens in London, they often have Nickolas Means give a talk about an aeronautic topic. It’s usually 45 minutes of nail-biting in-depth analysis of a very complicated problem, and ends with a 5 minute rotation to how the lessons from that incident apply to engineering management in general. (You also feel like you could engineer an airplane, but no you can’t: that’s just Nickolas’ talent for explanation that is fooling you. Airplanes are very hard to make.)
This is all done in such a smart, seamless, obvious way to deliver a lesson that would make the Brothers Grimm feel cheated.
This very specifically works for Accidents - events nobody actually wanted to happen, where we can learn from experience and prevent it happening again.
It specifically won't work for things which were not accidents at all, where blame remains a useful tool.
There's some nuance, the Captain of the Titanic didn't intend to sink the ship and kill loads of people, in that sense it was an accident - but he also didn't need to head into an ice field at full speed. Various UK politicians didn't set out to drive postmasters to suicide, but they did give political cover to business people they must have suspected weren't being truthful.
Any decent accident investigation should highlight that the Captain was under strict instructions from the ship owners to break a record, wealthy influential owners that could and would destroy his career if he failed to push the ship.
Good investigations identify causes with a view to prevent repetition of circumstances.
Cases like these (Titanic, UK Post) strengthen the case for whistle blower protection.
Among other things, the investigation into the Titanic accident gave us the requirement of having enough life boats for everyone and standards in how to evacuate a vessel.
Captains being pressured by mamagement / organization to do hazardous stuff is a thing still, in aviation as well as in seafaring.
SOLAS (Safety Of Life At Sea) an international convention (ie International Law agreed by most countries) is indeed in big part a result of Titanic. SOLAS covers a lot of safety improvements and has continued to improve over time especially after a later version of the treaty makes updates "tacitly accepted" basically instead of signing treaties periodically the members agree that they're all automatically bound by any changed rules unless enough of them object. SOLAS is handled by IMO, the UN's specialized agency for the sea, which is based in London, on the far side of the Thames not terribly far from Westminster.
Unfortunately the thing most people remember (and which you highlighted) is life boats and, perhaps those are actually a bad idea, at least for most ships.
Here's how that goes: SOLAS requires life boats, but almost always you won't use them. Titanic is a rare example of a situation where life boats are very useful, an ocean linear breaks apart in the middle of the ocean. In most cases you're not very far from land, and so almost always you just get the people onto land and maybe the ship is damaged/ destroyed or maybe not, that's just stuff and it's insured. Fire? Control the fire, go to port. Hole in the ship? Pumps control sinking, go to port. Engine failure? Tow the ship to port. So in all these cases you don't use the life boats, doing so is basically a last resort.
But, even though you would very rarely need them, likely never for a vessel which operates close to shore, they must be maintained periodically because SOLAS, and maintenance of lifeboats is pretty dangerous because they're on the outside of a ship. So you may end up killing or seriously injuring more people by having lifeboats.
But, even though you would very rarely need them, likely never for a vessel which operates close to shore, they must be maintained periodically because SOLAS, and maintenance of lifeboats is pretty dangerous because they're on the outside of a ship. So you may end up killing or seriously injuring more people by having lifeboats.
Did the designers of the Titanic write this? You're arguing having enough lifeboats for all your passengers is bad because you have to maintain the lifeboats
I'm confident that I did not design the Titanic, a ship launched before my grandmother was born IIRC, however yes, I'm saying that this trade might well not be worth it in the bigger picture, not for all the ships covered by SOLAS.
Titanic is the sweet spot for wanting more lifeboats, they had a long time, but they were in the middle of the ocean and nobody was coming to help.
If you go down very quickly lifeboats are useless. Herald of Free Enterprise could have had ten lifeboats per customer, wouldn't have made a difference, there were 90 seconds between nothing is wrong, and oops the ship is laying on its side in the water, lots of people are going to die in that scenario.
On the other hand if the port isn't far you can make for port. Despite a ship being on fire, or badly holed it may have hours left, the Titanic had almost three hours.
If the maintenance of life boats is so dangerous and even costs more lives than it is expected to save, then in my eyes it would be the right reaction to invest into safety procedures for life boat maintenance, not getting rid of life boats.
If more people are killed by installing and maintaining lifeboats than are saved, then why wouldn't it be reasonable to disagree strongly with the status quo on life boats?
They didn't argue that the maintenance is bad because its expensive. How could you miss that point? You literally quoted it in your comment:
Exactly. When we have an incident, I want us to be very clear about who did what, what they were thinking that led them to that course of action, and the other facts about the incident. Knowing which individual took which action and when is very, very different from holding an individual responsible (in terms of suffering repercussions) from it. If team members trust they won't suffer from it, you get much clearer data, often without even asking for it.
Related, I recommend that teams subject to SOX-404 controls consider adopting a variant of FAR 91.3*. Our SOX docs explicitly permit our incident managers (and two additional high-level tech employee roles) to authorize any action they deem justified during a production emergency.
