History has shown that man-made disasters occur due to factors that are controllable with fundamental safety initiatives. Basic controls placed on production, maintenance, operations, and quality will do the job if implemented as intended. Therein lies the rub—those, dare we say, “common sense” steps are always available yet often not fully embraced. The failure to protect life and property is maddening to those who understand safety.

Examples of these tragedies are numerous and easy to find. They occur in all industries, not just aviation. But they all have common causes that start and end in a disregard for safety procedures. Instead, they feature a focus on expedience, convenience, profit, or a combination of all. Additionally, they all result in the loss of life and significant property damage yet in the end no one is held accountable. Here are a few examples to consider:

March 25, 1911 - The Triangle Shirtwaist Company fire. 146 people died as a fire spread through the 8^th floor of the building. The shop was filled with cotton scraps and dust, exits were locked to prevent unauthorized breaks, and a flimsy fire escape collapsed. The owner was charged with manslaughter but acquitted and the company received more insurance money than the fire cost them.  

April 15, 1912 - The HMS Titanic sinks after striking an iceberg. 1,500 lives lost. No one was charged criminally or held accountable. The British inquiry exonerated the White Star Line calling the sinking “an act of God.” The U.S. inquiry was harsher in its criticism, but no charges were filed.

December 2, 1984 - Union Carbide India Limited, Bhopal India. A chemical release that resulted in 3,000-5,000 immediate deaths with an estimated 15,000-25,000 deaths over the ensuing years. The causes included refrigeration systems shutdown to save money, non-functional safety systems, substandard maintenance, and employees were not trained in emergency response. Union Carbide settled with the Indian government, but no executive was charged. A few local managers were convicted of negligence in 2010 (yes, 26 years after the disaster), but none served significant prison time.

April 20, 2010 - Deepwater Horizon offshore oil drilling rig explosion and sinking. 11 workers died, 17 injured. This was the worst petroleum accident in history spilling an estimated 134 million gallons of oil into the ocean 40 miles from Louisiana. Several companies (BP, Halliburton, and Transocean) paid significant fines for environmental crimes, destroying evidence, and poor maintenance practices. BP also pleaded guilty to 11 counts of manslaughter; however, no individuals were ever prosecuted or imprisoned. Ironically, the Deepwater Horizon was being honored on the very night it exploded — and the specific award was the “Transocean Safety Award for Excellence.”

These are extraordinary examples of how people in charge are rarely, if ever, held accountable for their failure to protect employees, subcontractors, or end users. But certainly, aviation has a better record in this regard, right? Unfortunately, aviation has its share of tragedy with no individual accountability. Again, a few examples:

1954 - Two in-flight breakups of de Havilland Comet jetliners resulted in 56 fatalities. The failures were caused by fatigue cracking of the fuselage originating from rivet holes and square corners from ADF window cutouts. The fuselage skin was made extremely thin to save weight. Despite clear design errors that resulted in fatal crashes no individuals at de Havilland or regulatory agencies were held accountable.

1972, 1974 - Two DC-10 cargo door failures resulting in one serious incident and one crash, 346 fatalities. Several design problems contributed to the door failures including an outward opening door (that must resist pressurization forces), lightweight aluminum latching mechanism, and the door could appear locked when it wasn’t. After the first incident, the FAA accepted a McDonnell Douglas service bulletin for a recommended change rather than insisting on a design change. Then Turkish Airlines 981 crashed. McDonnell Douglas blamed ground crews and maintenance and had fought redesign until after the fatal crash. No executive was held responsible and only relatively small civil payments were made.

2018, 2019 - Two new Boeing 737 MAX aircraft crashed resulting in the loss of 347 lives. Critical design and manufacturing errors involving AOA sensors and MCAS brought down the two planes. The FAA failed to act after the first crash despite knowing the aircraft had serious safety problems. Subsequent investigations determined there was a criminal coverup (Boeing pleaded guilty to defrauding the FAA) and recertification of the MAX was required. Despite the guilty plea the DOJ subsequently agreed to a non-prosecutorial agreement. No one at Boeing has been held accountable despite the significant loss of life. The MAX continues to fly with a long list of design and manufacturing defects.

There are many more examples, but the overall pattern is clear. Accountability is sacrificed to protect the system. These tragedies span over 100 years, yet the accountability failures are nearly identical. Unless the system is changed worldwide these shameful disasters will continue to happen with impunity. Civil settlements and reputational harm may occur but individuals who make decisions that result in tragedy will not be held responsible.

Corporations are protected in many ways. Responsibility is distributed throughout a large company with executives, managers, engineers, regulators, factory workers, and subcontractors all having a role to play. But this also makes it easy for those people to say, “it wasn’t my decision” or “I only played a minor role in a national project.” This makes it very hard to prove any criminal intent or individual negligence. In rare cases a CEO will take responsibility and may even be fired. But there will likely be no further consequences, and the golden parachute is often a staggering payoff.

Logically we should be able to depend upon regulatory agencies to ensure safety standards are met and these disasters are prevented. But that landscape is changing as regulators are relying more on the companies they regulate. In the case of the FAA, perhaps it simply does not have enough engineers, technical experts, or funding to regulate a large manufacturer such as Boeing. On the other hand, perhaps the FAA doesn’t have the strong leadership or the congressional support it needs to aggressively enforce the regulations. Boeing and the FAA have agreed that the Organization Designation Authorization (ODA) program is sufficient to ensure safety in design and manufacturing. Boeing selects the Authorized Representatives (AR) to act as FAA delegates. Although the FAA maintains certification authority, Boeing selects the ARs, they pay the ARs, and they have significant influence over the ARs. This is supposed to be a hybrid system, but it becomes something else.  It’s not hard to imagine how the FAA’s oversight responsibilities can become diluted by corporate influence. This “regulatory capture” has got to be stopped.

These examples are systemic failures which our legal system is not designed to address. We have replaced individual accountability with civil settlements. Although these settlements can be significant, they pale in comparison to corporate earnings. A payment, no matter how large, does not qualify as justice. Additionally, most governments are hesitant to prosecute individuals or bring down companies because of economic pressures. Money talks—that’s a reality of the global system. It will always be louder than the individuals who have been harmed.

The aviation safety system is designed to prevent accidents and make system improvements should an accident occur. Investigations must be free from bias and individuals must be candid about the circumstances of the accident. A fear of prosecution could inhibit truthful testimony and interfere with the investigation process. This is a fundamental of all effective safety investigations and vital to success. Having said that, separate proceedings should occur that focus on accountability. But the legal system is not designed to punish those who caused the accident for the reasons stated above. This is the reality; it is certainly not a perfect system. In safety we are most interested in why a disaster occurred so corrective measures can be implemented. We focus on ensuring the same accident doesn’t happen again. That is the right thing to do, but even that has flaws. There were safety regulations in place that should have prevented the MAX disasters. Yet the system failed to prevent them from happening despite those regulations and decades of other safety improvements.

Organizations such as Boeing and the FAA are quick to say how aviation is the safest mode of transportation. The government points to the most comprehensive aircraft certification in history that allowed the MAX to return to operation 20 months after the second crash. Boeing stands by their aircraft and are excited to tell us how many new jets they have sold around the world. But for those who really pay attention, for those who really know the industry, we see a concerning trend that continues to risk the lives of those who fly. The FAA has failed in its job in too many ways to count. The list of design and manufacturing defects on both the 737 MAX and the 787 Dreamliner are staggering. Will chasing the dollar and placating industry ever be less important than safety?

The system can’t be changed overnight, but we can take steps that move it in the right direction. A focus on accident prevention would effectively eliminate the need for accountability. The FAA must take the responsibility of holding manufacturers responsible for designing and building safe airplanes and the airlines for safe operations. After all, this is their primary responsibility. Their mission statement reflects just that: “Our continuing mission is to provide the safest, most efficient aerospace system in the world.”

It is time to hold the FAA accountable. After the DCA mid-air collision the FAA admitted that multiple FAA failures were the proximate causes of the crash. Despite this, no individual FAA employee has been disciplined, terminated, or criminally charged, according to all available reporting.  Once again, civil trials and the resulting monetary penalties will be the only justice for the victims and their families.

To the FAA we say no more noncompliance’s, no more exemptions. Enforce the regulations that are written in blood. Be proactive rather than reactive. Stop making assumptions and trusting that everyone truly holds safety as a top priority. That should start us down the right path. Along the way the FAA might even find a few individuals who are intentionally violating the law and hold them accountable.