When things go wrong, it’s easy to ask whose mistake it was. That’s where the «blameless postmortem» comes into play. It’s a process – a long-standing, internationally formalised tradition in aviation – that forces everyone to look beyond individual mistakes. «When liability is not a concern, an investigation has leeway to draw more meaningful conclusions». Which makes it easier to implement changes that will actually reduce future risk. Reminded me of this interview on why we should never accept that something has been «an accident».

From Weekly Filet #474, in January 2024.