The United States leads the world in airline safety. That’s because of the way we assign blame when accidents do happen.
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.
Annex 13 holds that the primary purpose of an aircraft accident investigation is to prevent future accidents — a decision that implicitly privileged prevention above the search for liability. Conducting a police-style investigation that faults a deceased pilot does nothing to affect the probability of future accidents. To follow the spirit of Annex 13, investigators must ask how others could be prevented from making the same mistakes in the future. This document, and in particular this provision, formed the basis for the modern practice of aircraft accident investigation. Most aircraft accident reports around the world today open with some variant of the principle, such as the NTSB’s disclaimer:
The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties…and are not conducted for the purpose of determining the rights or liabilities of any person.”
When liability is not a concern, an investigation has leeway to draw more meaningful conclusions.
