Rick Moen <rick@???> wrote:

> If you read the National Transportation Safety Board report on the Pan
> American World Airways flight 799 disaster that killed my father in
> December '68

I found that after you mentioned it earlier - it made sobering reading. You and your family have my sympathies, it cannot have been easy to come to terms with.
I apologise if discussing it causes any issues for you.

> , the crucial error (among several) was by an _unnamed_
> engineer in Pan Am service engineering who 'decided that [a recommended
> hardware] modification was not necessary', despite having carte blanche
> to do any fix costing less than US $50 per airframe and just expense it.
> An equally unnamed supervisor reviewed this decision and 'decided, after
> coordination with flight operations, that the bulletin was not
> applicable to Pan Am aircraft, and no further action was taken. The
> reason for this decision was not fully documented.'
>
> And no names.
>
> Names. Accountability. I rather like them.

On a flying related mailing list I'm on, there used to be a reasonably experienced pilot who pointed out that many issues are like ducks nibbling at your ankles - you can tolerate one or two, but when there's half a dozen then it's hard to ignore them. Reading the NTSB report, the thing that stuck out for me was how this was a real example of that - several small issues, none of which would have caused the crash on their own.

I also know that had I been in the position of that engineer or supervisor, then it would have haunted me that had I made a different decision at the time (which may well have been a rational decision based on the facts/understandings known at the time) then the outcome could well have been different. And I do know what that haunting is like - you manage to put the memory out of your mind, then it just re-appears (sometimes at random, sometime because something triggered it) and again you wonder "if I'd done something different, would they still be alive today ?".

I'm not sure that naming the people would necessarily help. I assume it could well have been any one of several engineers making that decision for that aircraft - so it was that person's bad luck to be the one (of several) that could have been responsible. Everyone in the team will have known, and the rest probably muttered to themselves "there but for the grace of god ..." at not being the one with the guilty conscience.

We see this a lot these days, someone makes a mistake, and the massed crowds (or media) bay for that person's blood (or resignation) - often successfully. I don't see that as constructive in the grand scheme of things - someone made a mistake, they aren't likely to make that mistake again, yet they are chucked out and along with them goes their skills & experience, so chucking them out deprives the future of the those skills & experience.

And lets be clear, this engineering decision was not *THE* cause of the crash - it was one of several ducks all nibbling at the ankles of fate. Changing it would almost certainly have avoided the crash, as would different weather, as would a change in the checklist, as would a change in the ATC pressures. I'm sure there were plenty of people arguing that it was the pilots' fault for not setting the flaps correctly - ignoring the human factors, engineering decisions, checklist deficiencies, ATC pressures, weather, etc.

I can also speak first hand about how things can quickly get out of hand. In my case I have less than 200 hours in light aircraft, and my "incident" left me with a reusable plane and no injuries other than to my pride. What to a bystander or myself in hindsight should have been a series of easy choices/decisions to make - become a totally different matter when the brown stuff is flying and your decision making process has turned to jelly.

So hypothetically speaking ...
What if the engineer had been named, and as a result was hounded out of the industry ?
Would that have undone the (what looks in hindsight to be a) mistake ? No it wouldn't.
What would have happened is that someone else would have had to step into the job, and somewhere down the line a new (probably junior engineer, new to the industry) employed. So overall, the level of skill and experience in the company has gone down - very slightly, but it's gone down. Does anyone benefit from that ? I don't think so.
Often, I think the only beneficiaries of such naming and shaming are those who somehow feel their loss has in some way been avenged. We all feel that our loss should be avenged - but that's not always the same thing as justice or what's best for society as a whole.
But every case is different. In many cases I agree that it is right to name those responsible, and in many cases it is a good thing if they are not allowed to continue in their trade.