In the medical world, we analyze incidents where people either die or have bad outcomes. These analyses are often in large meetings with many people involved, and are called "morbidity and mortality" reports. In these meetings, we will review all aspects of a case, with the specific purpose of finding opportunity to change practice patterns, assumptions, processes, and do better next time. No blame is made (correction: no blame is supposed to be made), and these are legally closed meetings, meaning what is discussed in the meeting stays in the meeting). We skip placing blame so that we can obtain the truth. If blame were assessed, then we are less likely to obtain the truth, because people are protecting themselves.
Although this is certainly a different venue, the A&I on SB affords us a similar opportunity to learn from past incidents, and change how we do things-this is it's purpose. Unfortunately, there is always a portion of us that tends to Monday morning QB an event, even if simply because we see more clearly the events in a linear fashion after the event. Who knows how we would act, if we were placed in a similar situation? We owe it to everyone to at least consider that point.
Another point to consider is that even in well-documented incidents, there really are several perspectives, and all add to the value of the analyses. Assuming anything is the objective truth is an error in thinking. I always hear these things and then think, "it may have been like that". Even when an official report is published, it does not (at least to me) represent the actual, complete, perfect objective truth. It's just a possible interpretation of the events.
In my work, unfortunately I encounter a lot of serious illness and death. That happens in life, and I see death and bad things happening in every part of our lives. Sometimes when on a walk, maybe while baking cookies, sometimes while diving. There may have been nothing anyone could have done to prevent this unfortunate incident. Additionally, in almost every case I've analyzed, there is always oportunity to improve, but that's because life and death are both complex, and in the moment (say during CPR for instance) we often (always) lack complete understanding of the events, the causes, etc.
Additionally, it is human nature to attempt to simplify the unknowable multitude of variables that come into play here. We also naturally want to assign blame. Neither helps in obtaining our objective. We can't consider all the variables because we frankly dont know or understand them all. However, we can objectively analyze what we have and what we can measure, realizing that we are lacking key information. And try to dress conclusions to act on, within the confines of our meager collection of data points.
No emotion. Facts. I dont pretend to understand someone's motives, not do I care, not should they play a part in our analysis. Our objective is to find opportunities to change our practice and codify best practices, either personally or professionally.
I appreciate the many insightful posts in this thread, it's opened my mind to many things I need to consider when diving.