This reminds me of the book "Black Box Thinking" that basically says it's more important to learn from mistakes so we don't repeat them than to assign blame. The commercial aviation industry does this better than any other industry, even medicine.
Yes. Blame is poisonous. Humans hate blame, they'll deflect blame onto the innocent, they'll lie and cheat, to avoid blame. The correct focus is prevention of future harm. Not "who is a bad person?" but "what will we do differently next time to avoid this outcome?".
In that frame suddenly the driver stops saying they weren't too drunk to drive and says next time they'll take a cab. The policeman stops saying the suspect "wasn't complying" and agrees that they need training on how to de-escalate situations.
Medicine does have tools for this, the M&M conference (medics discussing why somebody died or had a bad outcome and how to do better next time) is under-used.
Humans are fallible, blaming a specific human makes us feel better but does not prevent the same thing happening again.
I’m completely with you on this and have been implementing this in practice. Sometimes, however, I still meet resistance. Do you have any source/literature that underpins this method?
Blame isn't the only problem. Humans also hate change. Eliminating blame reduces the resistance to implementing better policies but does not completely resolve it.
Aviation accident investigations always assign blame when it can be determined. In this particular case [1]:
> The National Transportation Safety Board determines that the probable cause of this accident was the captain’s inappropriate response to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover. Contributing to the accident were (1) the flight crew’s failure to monitor airspeed in relation to the rising position of the lowspeed cue, (2) the flight crew’s failure to adhere to sterile cockpit procedures, (3) the captain’s
failure to effectively manage the flight, and (4) Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.
The primary purpose of the NTSB is to prevent future accidents. Any "blame" they assign is in furtherance of that purpose, not punishment. So critical is this to the NTSB's mission that any conclusion the agency draws as to the cause of an accident cannot be submitted as evidence of civil liability[1] in court and every NTSB report includes a footnote to that effect. You'll find it on page 4 of the document you've linked.
[1] The report would be hearsay in a criminal case and admissible only if the government demonstrates an exception to the rule against hearsay evidence.
The NTSB tries to determine "Probably cause". That's a far cry from assigning blame. In particular, on every NTSB report there's a big box specifically saying (my emphasis):
> The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, “accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties ... and are not conducted for the purpose of determining the rights or liabilities of any person.” 49 C.F.R. § 831.4. Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations.
Furthermore, to "ensure that Safety Board investigations focus only on improving transportation safety, the Board's analysis of factual information and its determination of probable cause cannot be entered as evidence in a court of law."
