In aviation post-event reports penalizing humans has usually the least priority, unless they intentionally violated the rules. If they did so unintentionally, or because they made a mistake, usually the entire industry gets better trainings, and/or system to prevent such. I'm generalizing here a lot.
Indeed. Punishing people for making human mistakes causes them to hide them, feel ashamed, and not highlight issues that may affect others. Aviation has fostered (very specifically) an open culture of inquisition to errors: it's assumed that if one qualified pilot made a mistake, any qualified pilot could make the same mistake under the same circumstances. If anything, you're actively encouraged to report things that are either confusing, or situations when you nearly made a mistake – the gliding club I spent a lot of time at in the past explicitly encouraged issues to be reported and put them in their monthly newsletter. Root cause analysis is a wonderful thing, and sometimes very convoluted and interesting.
I'm sure the outcome of this event will probably be a technical mitigation of some variety to attempt to stop it happening again.
This move was championed in the industry by John Allspaw, then CTO of Etsy, around 2010. I am under the impression that he introduced the idea of blameless post mortems but I could be misremembering.
That one I'm well aware of, but in his case part of the disaster already happened. I'm asking about pre-disaster (preventive) situations like this one.
No, mainly they identify the contributing factors and work to correct them. For a specific example check Air Canada 759, which nearly landed on a crowded taxiway at SFO in 2017. No one involved was fired afaik.
Although there were certainly many "systems factors" that contributed to the incident, the followup treatment of the pilots is in fact remarkable. The Wikipedia summary of the incident is "near miss attributed to pilot error". This pilot error nearly killed a thousand people. The pilots failed to report the incident (even flying the return flight the next day) and thus overwrote the cockpit voice recorder for the flight.
And despite all that, the names of the pilots are not included in the NTSB's report and Wikipedia editors/moderators think they shouldn't be included in that article. Impressive job security.
They have to call the controller and explain what went wrong. They'll then have to chat to their chief pilot over tea and biscuits minus the tea and biscuits. If they're honest, I doubt anything will come of it, even if they were violating some other regulation.
