In bringing the official investigation into the Hudson River landing of USAirways flight 1549 to a close on Tuesday, the National Transportation Safety Board did not conclude the ditching seen 'round the world was a miracle.
"Even in an accident where everyone survives, there are lessons learned and areas that could use improvement," said Deborah Hersman, the chairwoman of the board.
It is a valid and important point.
The so-called Miracle on the Hudson, fits into no category better than "other", still there are those who would rather it be the poster child for a different way of looking at transportation safety, including the man who has become an icon of the event, Capt. Chesley Sullenberger.
At present, the popular gauge of safety is fatal accidents. No fatalities = a safe year. This is not true of course, but it is an easy leap and journalists as well as the general public often jump to that conclusion.
In 2006, the International Society of Air Safety Investigators held a conference in Mexico. While the sun beamed outside our overly chilled conference center, the spotlight for three days was not on accidents but incidents.
What's the difference? Accidents wind up on the evening news. Incidents do not. They are the near-hits, the "What the f-?", the there-but-for-the-grace-of-God-go-I events. Most of the time, passengers don't even know they've been in one.
If the idea of discussing what didn't happen sounds like a big snooze, let me assure you, it is not. Start with the premise that every accident lies at the end of a chain of events. To prevent that accident only one link in the chain has to be broken. In this reality, non-events are exciting because they are exposing the places where accidents can be prevented.
This is what Ms. Hersman is talking about when she sends a delicate sprinkling of rain on the parade of accolades that have deluged everyone and everything associated with USAirways Flight 1549.
During the controversy over two books about the accident, Chesley Sullenberger's Highest Duty and William Langewiesche's Fly by Wire, which I wrote about for The New York Times, Capt. Sullenberger told me he was counting on the safety board to properly credit the many links in the chain of events on January 15, 2009.
At the time, he was referring to Langewiesche's book in praise of the French designed Airbus A320 with its highly automated cockpit. But in subsequent conversations, Capt. Sullenberger continues to insist that it is not about the airplane, or the pilots, and a proper allocation of credit is critical.
"This outcome was the result of more than one person," he told me. "Among the things that went right you have to have a clear understanding of the degree to which each of these factors contributed and they have to be weighed in an accurate way."
Why didn't the 150 passengers and five crew members drown in the frigid waters of the Hudson River on that day in January? Why didn't the loss of engine power contribute to a stall of the airplane? Why didn't the pilots and flight attendants make critical errors in judgment faced with a horrifying lack of options shortly after takeoff?
Asking these questions turns the traditional investigation on its head. Asking why events went right can be as illuminating as examining the events that have gone tragically wrong.
In a presentation at the conference in Cancun, safety engineer Richard (Dick) Wood recalled having often been told "'If we want to prevent accidents, we have to work on preventing the incidents first.' Is that true? Yes it is."
I'm not alone in criticizing manufacturers and regulators for taking a tombstone approach to safety. When enough people die, a previously identified problem will get fixed. (When I worked in television news we had a variation we called the "if it bleeds it leads" decision.) Accidents capture public attention which turns to public pressure which results sometimes in changes to policy or regulation.
But Mr. Wood's presentation makes it clear there's more to it than that.
"We have neither the time nor the resources to investigate everything that might be reported as an incident under current reporting rules. We can't do it! An actual accident is the least likely result of a particular series of events," he said. "Because our ability to investigate everything is limited, we are in the position of waiting for the least likely event to occur and then investigating it thoroughly. This is not a proactive approach to safety."
As the opposite of the tombstone mandate, glimmers of a comprehensive program to investigate incidents can be seen in confidential reporting programs and flight quality monitoring. Now, the chairwoman of the safety board is talking about room for improvement even in extraordinary events and 155 living breathing souls provide her with a backup chorus. Its enough to make one believe in miracles.
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