Secretary of Transportation Sean Duffy seems intent to repeat the mistakes of the past.  While responding to an NBC Nightline interview question regarding the recent spate of aviation accidents and incidents (most recently to the interview, a private jet inadvertently entering an active runway in Chicago Midway Airport causing a Southwest flight to execute a go-around to avoid collision) Secretary Duffy stated that pilots should lose their licenses for making mistakes

Look, I get it.  This new administration was barely sworn in and the worst aviation accident in nearly two decades occurred when a military helicopter struck a regional jet on approach to Washington National Airport, claiming the lives of 67 people.  Then, in short succession, a small jet crashed in Pennsylvania, a jet tumbled upon landing in Toronto, and the aforementioned near-miss in Chicago Midway.  Secretary Duffy had to appear that he was fighting to make the skies safer to a frightened public.  The problem is, he wasn’t willing to find a cause; only a scapegoat.

Aviation has become an incredibly safe method of travel and is looked to as the gold standard for safety.  According to the FAA, commercial aviation fatalities have decreased by over 95% since 1998 as measured by fatalities per 100 million passengers.  Additionally, the fatality risk (percentage of an accident or loss resulting in death) decreased 83% during the same time frame.  The International Air Transport Association, an organization which represents and advocates for airlines across the globe, recently published their 2024 Safety Report finding that the all-accident rate globally improved significantly over the period 2020-2024 with almost half the accidents than the previous decade (2020-2024: 1 accident per 810,000 flights; 2011-2015, 1 accident per 456,000 flights).  These improvements in safety coincide with various FAA and global safety efforts and a shift from blame-seeking behavior to information-sharing.  I discuss these initiatives more completely in a previous blog post.

Alright, Mr. DeMille, Secretary Duff is ready for his close-up.  Looking good for the cameras is all part of the political game.  But unintended consequences lurk behind every well-intentioned comment and policy.  All humans make mistakes; short of outright sabotage or negligence, we are going to do the wrong thing from time to time unintentionally.  Secretary Duffy’s intent is to hold people accountable for their (in)actions and reduce unsafe events. But by not acknowledging that there is a difference between a mistake (which is correctable by individual retraining or systemic change) and gross negligence, criminal action, or a blatant disregard for safety (which would normally be the threshold for licence revocation) instead incentivises people to not voice safety concerns and hide mistakes out of fear for retaliation.  This, invariably, leads to higher accident rates as no quarter is made to learn the actual root cause of the accident and to learn from it.  Under a punitive model, there is no incentive to be honest: either way, your livelihood is at risk.  It can take years to get your licence back, and even then, good luck finding a job.  So, if you’re honest, you risk losing your career.  If you’re able to hide the mistake, then at least you have a chance of making it through unscathed.  The net cost of dishonesty is decidedly lower than the net cost of honesty.  

In the aftermath of the Chernobyl disaster, Grigori Medvedev, the deputy chief engineer, described a “conspiracy of silence” culture encouraged by Moscow to build public confidence in nuclear power. Safety concerns went unreported and those that were went unaddressed. After all, unreported incidents cannot catch the attention of the public.  In short, the intent was to show the public a face of an ultra-safe nuclear program.  The reality was that deviation from the standards and safety protocols were becoming the new normal, as long as they were kept out of the public eye. Following this disaster, the concept of “safety culture” began to arise and by the early 2000s we began to see a downward trend in accident rates in aviation; researchers such as Dr. James Reason (see Human Error, 1991) and Atul Gawande (see The Checklist Manifesto, 2009) realized we had to shift that incentive back into the favor of safety reporting and prevention.  We refer to this as a “Just Safety Culture”; a fair and transparent approach where individuals are not blamed for mistakes or errors, but held accountable for reckless or negligence.  The goal of our just safety culture is to incentivize the open and honest flow of safety related information, and allow for continuous improvement of systems.   I am concerned that we would move away from a policy that encourages a just safety culture backed by decades of empirical data for that of a retribution culture and an unintentional return to the conspiracy of silence.

 


Dennis Murphy is a professional airline pilot with a background in aviation safety, accident investigation, and causality. When he’s not flying 737s, he enjoys the company of his wife, their dogs, cats, and bees.



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