The United States leads the world in airline safety. That’s because of the way we assign blame when accidents do happen. Kyra Dempsey, aka Admiral Cloudberg, explains the governing norms of post-accident investigations:
It’s often much more productive to ask why than to ask who. In some industries, this is called a “blameless postmortem,” and in aviation, it’s a long-standing, internationally formalized tradition. In the mid-20th century, when technical investigations of aircraft accidents were first being standardized, an understanding emerged that many crashes were not the result of any particular person’s actions. Most famously, in 1956, the Civil Aeronautics Board’s Bureau of Aviation Safety, the predecessor to today’s NTSB, concluded that no one was at fault in a collision of two airliners over the Grand Canyon because the two crews likely could not have seen each other coming until it was too late. The cause of the accident, they determined, was the lack of any positive means to prevent midair collisions.
The exact origins of this norm are debatable, but we might speculate that it arose from several factors, including the lack of survivors or witnesses in many early aircraft accidents, which left scant evidence with which to assign fault; the fact that pilots held high status in society and many were reluctant to blame them in the absence of such evidence; and the presumption that flying was dangerous and that disaster was not always an aberration of nature. These realities likely predisposed aeronautical experts to think in terms other than blame.
The end result was that the aviation industry became one of the first to embrace the concept of a “blameless postmortem” as a legally codified principle underpinning all investigations. In 1951, compelled by the reality that their industry was not widely regarded as safe, aviation experts from around the world gathered to compose Annex 13 to the Chicago Convention on International Civil Aviation. This seminal document aimed to standardize the conduct of air accident investigations among all member states of the International Civil Aviation Organization.
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