Have you ever noticed the military does not use the term “accident” or “accident investigation?” They use the term “mishap.” The reason, I think, is that all these “unintended occurrences” are driven by human actions and not some invisible “hand of god.” The term “accident” seems dismissive like “stuff happens” or the passive voice “it broke.” In this larger viewpoint, there are really no “accidents,” without cause. There is always a chain of events and actions that lead to a “mishap.” Learning requires taking responsibility, and a “mishap investigation” usually gets to the root cause. A lot can be learned from careful analysis and examination. MIshap investigations reveal an active path of flawed decisions and/or activity. There is usually some negligence and lack of vigilance involved too. A “mishap investigation” seeks to really drill down on this series of events and learn/improve from each occurrence.
When loss of life or equipment occurs (or the Space X “rapid unplanned disassembly”RUD) the military investigates each very comprehensively and uncovers the series of steps that led up to the unfortunate end result. The motivation of each investigation is an improvement or more comprehensive knowledge. This is a positive motivation, to seek a better, more efficient and successful, system. Hopefully, this prevents similar unhappy results in the future.
This grammatical distinction may seem trivial to some, but I would argue this inspires a whole different mindset in how we regard these events. The word “accident” is dismissive. “Accident” seems to say, “it happened” by some outside force. The legal definition seems to bear out this perspective:
“Accident” in law : “an unexpected happening causing loss or injury which is not due to any fault or misconduct on the part of the person injured but for which legal relief may be sought”
Even if an outcome is desirable, every organization and pilot should reflect constantly on their performance. This is the only way to improve. As mentioned in many other blogs, a successful outcome by itself is not always a cause for celebration and reinforcement of those procedures. We must always reflect after every activity asking important questions: “Were proper procedures and skillful execution the reason for success or did we luck out?” Is the final outcome repeatable or desirable following SOPs?” Fly safely out there (and often)!
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Testing comments…new blog format soon!
David and I are running an MIR. (Military for “Major Incident Report” on the blog.
This post is a test.
OK, Dudley…I think we got you back “on the air!” Thanks for your persistence, your input is always valuable (and appreciated)!
I think we nailed it.
It’s been a few years but I thought when the Air Force suffered a loss they would initiate two boards. The first was an Accident Board that would technically figure out what happened. The second was a Safety Board which was aimed more at the why of an incident. Between the two they’d decide what changes were needed to prevent a reoccurrence.
One board was convened for legal reasons… the other for safety reasons. The two boards were independent and did not share privileged information. True across all branches of service. I was a Naval Safety Center IIC.
There are two boards… legal and safety. They are separate boards and do not share priveleged information. All military branches follow these Olivier. I was a Naval Safety Center IIC.