Earlier today, two Qantas Airbus aircraft carrying a combined total of more than 600 passengers came close to colliding over the Gulf of St Vincent. The Australian Transport Safety Bureau (ATSB) commenced an investigation into the incident.
According to the ATSB website, the investigation will include:
- the review and analysis of the recorded radar and audio data
- the review of relevant air traffic control procedures, documentation and training
- interviews with the air traffic controllers and flight crew.
The procedures followed after aircraft incidents are excellent models of good decision making philosophies and processes. According to the ATSB 'the object of a safety investigation is to identify and reduce safety-related risk' and 'It is not a function of the ATSB to apportion blame or determine liability'. The ATSB even publishes mistakes so that the aviation industry can learn from them.
Imagine if all workplaces took an inquisitorial response to complaints, mistakes, poor performance or misconduct with the aim of the entire organisation learning from the data. Yet the usual reaction to error - if there is one at all - is to find a bad person, punish them, and impose more policies and regulation to move power further up the management hierarchy away from line management. The whole process is usually kept secret to 'protect' everyone's reputation.
Organisations often confuse good decision making with decisiveness. Policies set artificial timelines for complaints to be resolved and managers react to information rather than deliberate upon it. If decisions do take a while it is usually through inaction rather than because of measured analysis.
Yet when does the ATSB predict that it will complete its investigation into today's incident?
September 2014. 600 lives were potentially lost. No hurry.
(I wonder if it's actually just adopting another good decision making tip of under promising and over delivering.)