“Free lessons” in aviation safety

The aviation industry has traditionally been good at learning from its accidents: a global network of government run accident investigation organizations and the high media profile given to any major aviation disaster helps to ensure this. As commercial aviation successfully reduces its accident rate the opportunity for learning from accidents diminishes and learning from potential accidents becomes more important. Ironically, however, this success can generate a culture that minimises the perceived potential of incidents and becomes less likely to learn from them. The key to overcoming this is in generating a culture that has the desire to maximize the lessons for safety from any opportunity and openly share that learning. To succeed, this culture has to overcome the human and organizational desire to find a single cause and attribute blame. Invariably any accident is a chain of events and occurrences that come together in a tragic way and there are often many solutions to even the simplest incident. An incident that doesn't lead to a loss of life or significant financial burden should be seen as a “free lesson”, simply an opportunity to see how the system and its components broke down to allow the event, or more importantly one worse, to happen. Any system and ultimately any person is prone to failure and hence blame is of no value, understanding where the failures are likely to occur and how to minimise their potential is important.