Robin Lee Wascher was working as an air traffic controller at LAX in February 1991 when she made a simple mistake—one anyone could have made—and USAir flight 1493 collided with a commuter plane on the runway when it landed, killing all 12 people on the smaller plane and 23 people on the USAir flight. Because of the way the United States handles the aftermath of aviation tragedies, Wascher came forward as soon as she realized her error and explained what happened, knowing that information would not be used to punish her, Asterisk reports. The investigation that followed uncovered a host of systemic issues that all came together to create the circumstances in which the collision happened—from a troublesome ground radar system and visibility issues to the lack of an alarm system and a problematic information transmission hierarchy.
All of those issues were fixed, thus making US air travel even safer. This, the magazine explains, is the power of the "blameless postmortem," in which no one is punished in the aftermath of a tragedy like this: Rather, the goal is to look at the larger picture and figure out how to prevent the same thing from happening again. "Investigative agencies like the NTSB rely on truthful statements from those involved in an accident in order to determine what happened and why, and the truth can't be acquired when individuals fear punishment for speaking it," writes Kyra Dempsey. The gripping piece, which also includes an illustration of what happens when the "blameless postmortem" is not the norm, can be read in its entirety here. (More Longform stories.)
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