“I’ve seen more headlines than I’d like that start with the words ‘ATSB blames’. We don’t.” Says the Australian Transport Safety Bureau Chief Commissioner Martin Dolan in his latest blog. While he explains the actual no-blame position of the ATSB he opens the question of whether his, and other investigation agencies are doing enough education of the public and the media about what they actually do.
As we all know there are two flavours of accident investigation – those intended to uncover the root causes of an incident and the other basically aimed at hanging whoever can be blamed, usually the master.
As Dolan says: “This approach has major benefits for improving transport safety. Our acting consistently in accordance with the ‘no blame’ principle ensures people are willing to give us lots of sensitive information without fear that the information will be used against them. This helps us understand dimensions of an accident or incident that might otherwise be unknown to us.”
It can be difficult for the bereaved and those who represent them, to understand the no-blame principle, as efforts to make MAIB recommendation mandatory following the girting of the tug Flying Phantom show. Recommendations from earlier incidents had not been implemented.
Indeed, MAC himself discovered the difficulty of explaining no-blame principles during talks regarding the stillborn Philippine maritime investigation system. Lawyers accustomed to quasi-judicial fault-finding found the no-blame principle difficult to understand, insisting that witness should be subpoenaed to appear before the Board of Marine Inquiry and punished if they did not do so, for instance. The Philippine remains without a professional, competent investigative body that meets IMO compliance and is unlikely ever to do so. The blame culture is too embedded.
The need for education in no-blame principles and why and how they work and why they are successful may not only help the general public have a better understanding but may be important in helping bring jurisdictions which currently lack such a system up to speed.