I said somewhat unpopularly at the time that this is not an incident that should meet with curious blameless fact finding but instead the many responsible parties need to be stomped for negligence by the legal system.
Boeing’s board needs to be fired and some executives probably need jail time. Given the defense position of Boeing, the executive branch should probably take some direct action outside the judicial system once there are some more clear cause and effect facts about what’s going on at Boeing.
> not an incident that should meet with curious blameless fact finding
The NTSB "fact finding" is intentionally and necessarily blameless, because if it becomes a prosecutorial investigation then you lose cooperation of everyone involved. If you lose that cooperation, you can't work out what caused an accident, and so the same accidents keeps recurring.
The entire point of the NTSB is to find what caused the accident, and that's not going to be "Sarah was tired that day", "Frank was distracted by his kid's academic struggles", etc. That might be relevant (a common action by budget carriers use to be frequent schedule changes for line pilots, so that they had "sufficient" sleep by the law but were being forced to work through their circadian low, etc - stopping that took multiple crashes where the NTSB said "this is the cause"), but it isn't going to be the cause here. Afaict it takes multiple people to install the plug, all of whom failed to do or check the bolts, Boeing has a lot of cross checks, none of them caught this, Alaska did an acceptance flight and had performed maintenance, but did not catch this, etc.
Firing the mechanics involved doesn't tell you why they messed up, it doesn't tell you how this got through checks, it doesn't do anything other than provide retribution. It doesn't even do anything to the people who presumably created the environment that allowed this to happen.
So instead of trying to get retribution, we try to discover what made it possible for this to happen, so we can stop the same thing happening again in future. That is how flying got as safe as it is today.
People who cause accidents due to criminal behavior, or corporations that cause the accidents due to criminal behavior, can be charged or sued, but saying "I want people punished so lets sabotage the accident investigation, and inhibit our ability to prevent them in future" is counter productive.
>The NTSB "fact finding" is intentionally and necessarily blameless, because if it becomes a prosecutorial investigation then you lose cooperation of everyone involved. If you lose that cooperation, you can't work out what caused an accident, and so the same accidents keeps recurring.
The NTSB is a lovely organization but they're already calling out Boeing for not cooperating. They should continue doing what they're doing but a separate independent criminal investigation is in order. Jail time and large fines also help accidents from not recurring, preferably also legislative action and Congressional investigations. What is actually in order now is the legal discovery process to uncover what people are talking about, recording, failing to record, and otherwise documenting to bring to light the sources of the failed safety and reliability of these planes.
> Boeing’s board needs to be fired and some executives probably need jail time.
You're advocating for punishing specific people before any evidence has pointed to their guilt, which feels like the opposite extreme of treating everyone as blameless (which is also not what blameless fact finding is about, as other replies correctly pointed out).
>which is also not what blameless fact finding is about, as other replies correctly pointed out
Blameless fact finding is for dealing with errors and failures made in good faith. Far too many things have happened for these to be "good faith" errors and evidence and attitudes which have come out have made this plain. You stop being nice about it when foul play is the most reasonable suspicion at this scale.
>You're advocating for punishing specific people before any evidence has pointed to their guilt
The Boeing board should be replaced for what is already public.
>executives probably need jail
Notice the qualifier "probably". What I'm saying is this is what criminality looks like, the exact nature is still being investigated, but it should and is now being investigated like a crime instead of the normal flow for accidents which is the blaming fact finding which is only useful when everybody is actually interested in safety.
The blameless fact finding is necessary to know who to blame. The NTSB needs to know the answers to a bunch of whys about how things got to this point so they can work to prevent it in other aircraft. That requires them using their time-testing blameless process.
Afterward, criminal prosecutors can use those facts as leads to pull on when doing their investigation.
I don't think "blameless" means nobody can ever be held responsible if they actually did something truly malicious, negligent, etc. It's that the point of the investigation is to improve the system rather than assign blame. This is in stark contrast to the post by 'colechristensen assuming that someone must be responsible and that they should be "stomped for negligence".
I do think the person you're responding to phrased it poorly though. While a blameless investigation can result in someone being held liable (i.e. "blamed"), an equally valid result could be that nobody is blamed when no individual liability is warranted by the facts.
I suspect the people charged will be low level mechanics and assembly people and maybe a first level manager for appearances sake. You really think anyone at the executive level is getting arrested for this?
But to some extent it only proves the point. Boeing has been fucking up so badly for so long that the Feds won't give them anything that isn't a fixed price contract.
What makes people so convinced the door plug problem is obviously something that should be blamed on the executives? At the risk of being accused of shilling for corporate executives, convincing yourself that low level people can't be responsible for an issue before responsibility is determined feels like the wrong approach.
Part of being a leader is taking responsibility for the actions of those you are in charge of. Obviously it wasn't an executive who failed to properly install bolts, which is the proximate cause of the failure, but someone above the worker should have noticed the missing bolts when they were doing the documentation, someone above that should have noticed the missing documentation when they were auditing, and someone above that should have noticed the missing audit, and so on and so forth up the ladder until you get to an executive that doesn't have someone doublechecking their work. Now maybe the problem was noticed and an executive did take action but for some reason a subordinate deceived their superior into thinking they were following the directions when they weren't, but that seems at best highly unlikely. Even if that is what happened, the deception would have to be very elaborate for the executive to not be responsible for independently verifying that their orders were being properly followed. For better or worse, you don't get to take credit for the successes of those beneath you without also taking the blame for their failings.
I have a couple books here that carry terms like DO-178C, ISO 26262, IEC 62304 and so on on their covers. All that paperwork, all these processes, all that has a single reason: To make doubly^N sure that humans, who love to do all sorts of mistakes, don't.
Creating environments where these processes are kicked into the bucket in whatever way is NOT what workers do, it is coming from the very top. Do I need to continue on ... ? Maybe about what happens to workers if they try to do the right thing? Ever heard about engineers at Boeing who spoke up ... ?
It is time the head honchos not just at Boeing but more generally get to see that accountability, responsibility, and all these other fancy words also have some actual meaning. We have to stop playing this stupid game of "deferred responsibility", because in the end it is not a company but humans making decisions and there are always consequences from that. Some just take a while to cause some effects and not all of them take the direct route, either. But that doesn't make the decision makers less/not responsible.
>You really think anyone at the executive level is getting arrested for this?
There is a current smell of Boeing not being particularly cooperative with investigation. That is the usual path that gets somewhat more important people charged for committing crimes. Various brands of lying, conspiracy, and evidence tampering where people get charge for what goes on during the investigation instead of the actual incidents.
I said somewhat unpopularly at the time that this is not an incident that should meet with curious blameless fact finding but instead the many responsible parties need to be stomped for negligence by the legal system.
Boeing’s board needs to be fired and some executives probably need jail time. Given the defense position of Boeing, the executive branch should probably take some direct action outside the judicial system once there are some more clear cause and effect facts about what’s going on at Boeing.