Final report on Alaska Airlines Flight 1282 in-flight exit door plug separation

Also, I really appreciate the way they put blame where it belongs. They don't say "manufacturing personnel failed to ...", they say "Boeing failed to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly ...".

They know their business. The goal is safety, not punishment. Blaming workers is great if you're after revenge or a scapegoat, but generally doesn't improve safety.

Agreed about properly assigning the root cause to inadequate training but the sentence was unnecessarily complex in not making the first order cause clear until the end. I'd prefer stating up front that the first order cause was "securing bolts and hardware that were removed to facilitate rework" were not reinstalled - and then stating the root cause leading to that being inadequate training.

In the context of a summary I just expect the core sentence to take events in order from the headline failure ("in-flight exit door plug separation") and then work back to the root cause.

Right, Alaska didn't buy an aeroplane from "manufacturing personnel" they bought it from Boeing. If Boeing don't want to sell aeroplanes that's cool, bye-bye Boeing, but if they want to sell aeroplanes then it's their responsibility to ensure those planes are safe and it cannot somehow be a transferable responsibility.

In the end - action matters. Somebody didn’t put the bolts back in.

Yes - zooming out it important and ultimately where actionable remediation can be applied - but blame is due where blame is due: somebody fucked up at work and it almost brought down a plane.

Modern safety analysis acknowledges that humans are fallible, and they are generally acting in a good faith way to try and do their jobs correctly within a given system they are operating in.

That's why these reports tend to suggest corrective actions to the parts of the system that didn't work properly. Even in a perfectly functioning safety culture, an employee can make a mistake and forget to install the bolts. A functioning safety system has safeguards in place to ensure that mistake is found and corrected.

In the end, identifying where you can usefully take action to reduce the chances of something similar happen in the future is far more useful than assigning blame.

Assigning blame is often the antithesis of safety.

In aviation and other safety-critical fields, we use a just culture approach — not to avoid accountability, but to ensure that learning and prevention come first.

https://en.wikipedia.org/wiki/Just_culture

Super underrated point - and one that I am not sure the general public always keeps top-of-mind, as human imperfection should be the default assumption. The whole system of air travel is designed so that wherever possible, multiple f*ck-ups can occur and not result in a catastrophe. The success of people involved with anything touching on aviation safety is best measured as in "how many f*ck-ups can occur in the same episode and have everyone still walk away alive?" If you can get that number up to 3, 4 complete idiotic screw-ups one after the other, and the people still live, you've really achieved something great.

Yes! It's basically better to take all screw-up(s) and make their recurrence the assumption. 'Given people will forget to replace bolts how can we best make it so the plane cannot exit the factory without the bolts in place?'

There's a reason why Murphy's Law is so commonly acknowledged, though. When you've got a process like this that gets repeated over and over by a bunch of different people, you simply must recognize that that, if it's possible for someone to fuck up, then somebody will fuck up.

And a relatively straightforward corollary of that reality is that, when somebody fucks up, putting too much personal blame on them is pointless. If it weren't them, it would have been somebody else.

In other words, this "blame is due where blame is due" framing is mostly useful as a cop-out excuse that helps incompetent managers who've been skimping on quality controls and failsafes to shift the blame away from where it really belongs.

> They don't say "manufacturing personnel failed to ...", they say "Boeing failed to provide adequate training, guidance, and oversight necessary to ensure that manufacturing personnel could consistently and correctly ...".

Doesn't this mean it should happen a lot more?

If I remember right: during the checks before they were allowed to fly again after being grounded after this incident, multiple operators found issues with the bolts for these door plugs on their planes.

This is absolutely incorrect. It runs counter to every high functioning safety culture I've ever encountered.

The system allowed the human to take the incorrect action. If your intern destroys your prod database, it's because you failed to restrict access to the prod database. The remediation to "my intern is capable of destroying my prod database" is not "fire the intern" it's "restrict access to the prod db".

Even the best trained humans will make errors. They will make errors stochastically. Your systemic safety checks will guard against those errors becoming problems. If your safety culture requires all humans to be flawless 100% of the time, your safety culture sucks.

So no, this isn't a fault with a human. Because this was a possible error, it was inevitable that at some point a human would make that error. Because humans never operate without errors for extended periods of time.

> There's a reason why Murphy's Law is so commonly acknowledged, though.

In particular, the original formulation of Murphy's Law. The folk version has morphed into "anything that can go wrong, will go wrong". But the original was "If there are two or more ways to do something and one of those results in a catastrophe, then someone will do it that way".

These investigations are about identifying root causes, not assigning blame.

Others already said it but since I'm the person you responded to, I'll reiterate that my suggestion was only about reordering the sequence of that sentence for better clarity, not about placing blame on individuals over process. When a failure can cause serious consequences including killing people, proper system design should never even permit a single point of failure to exist, especially one relying on humans to always perform correctly and completely. Even well-trained, highly-conscientious humans can make a mistake. While these people should have received better training as well as comprehensive sequential checklists, a good system design will have critical failure points such as this each verified and signed off by a separate inspector.

The problem with a culture which prioritizes "blame is due where blame is due" is it can cause people to not report near-misses and other gaps as well as cover-up actual mistakes. The shift in the U.S. from blaming (and penalizing) occasional pilot lapses to a more 'blameless' default mode was controversial but has now clearly demonstrated that it nets better overall safety.

Have you read Donald Norman's Design of Everyday Things?

Yes and, IMHO: docs, procedures, checklists, etc. strive to mitigate the challenge of assumed knowledge. It's a wicked hard problem.

"Identify and publicly anounce" vs "assign blame", what's the difference?

> the sentence was unnecessarily complex

I don’t see it that way. It’s designed for consumption by educated readers. A press release can dumb it down to middle-school reading level so the media can dumb it down to grade-school level for the masses.

Identify root causes so they can be prevented or mitigated in the future.

vs.

Figure out who to sue.