Kyra Dempsey in Asterisk:
In the aftermath of a disaster, our immediate reaction is often to search for some person to blame. Authorities frequently vow to “find those responsible” and “hold them to account,” as though disasters happen only when some grinning mischief-maker slams a big red button labeled “press for catastrophe.” That’s not to say that negligence ought to go unpunished. Sometimes there really is a malefactor to blame, but equally often there isn’t, and the result is that normal people who just made a mistake are caught up in the dragnet of vengeance, like the famous 2009 case of six Italian seismologists who were charged for failing to predict a deadly earthquake. But when that happens, what is actually accomplished? Has anything been made better? Or have we simply kicked the can down the road?
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.
More here.