Crime and Punishment.
'The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability.'
- Clause 3.1 to Annex 13 to the International Convention on Civil Aviation
Vengeance. Retribution. Revenge.
Deterrence. Punishment. Justice.
Blame.
We have a powerful longing for these outcomes from decisions that follow errors.
Maybe its a carryover from our childhood. Parents. School. Discipline.
If there's an error and no-one gets publicly named and shamed, it's like an enthusiastic waiter has cleared our coffee cup from our table before we've drunk the last mouthful.
Perhaps we're trained in our thinking and expectations by stories from books, movies, and the news about the adversarial winner-loser criminal justice system that relish arrest, prosecution, trial,confession, admission, guilt, judgment, verdict, conviction, sentencing, penalty.
There are no blockbuster movies where the hero rises to her feet in the middle of an Administrative Appeals Tribunal hearing and shouts 'You can't handle procedural fairness and natural justice and correct or preferable decision making in the inquisitorial process!' It's Crime and Punishment that is the classic bestselling literary novel. Not Ultra Vires and Certiorari.
Listen for assumptions about blame and punishment lurking ominously just beneath the surface of the benign, dull, haze-grey drone of our organisational language. 'Accountability' doesn't mean 'We'll celebrate and reward you and eagerly learn from you when it all goes well.' We know it really means 'Don't you screw it up - or you'll pay for it.'
Laws that were designed as shields to protect people are brandished like swords and waved menacingly towards us. Or instead of serving as cobblestones meant to pave society's streets of mutual progress, laws are seized by an aggrieved person grasping for reasons for some calamity and prised loose from their intended legal context to be used as missiles to hurl and draw blood from anyone deemed at fault.
The inquisitorial system is so alien to our thinking compared to the adversarial one, and our Whodunnit expectation so strong that it must be managed. Watch and listen to Datuk Kok Soo Chon, the Investigator in Charge of the Malaysian Airlines MH370 disappearance, solemnly repeat word for word Clause 3.1 to Annex 13 of the ICAO Convention as part of his Interim Report on the investigation as he looks down the barrel of the camera at you and me. 'You'll not find blame here,' he's saying. 'We're not going to give you a head on a platter,' he's warning us in more austere bureaucratic language. 'There's nothing more to see here except lessons for a better future.'
To paraphrase Clause 3, the sole purpose of a good decision should be to make a better decision next time.
There's also a lot of learning between 'It fell' and 'I dropped it'.
We don't become who we are on the back of the shamed and fallen.