Gongol.com Archives: February 2023

Brian Gongol

February 1, 2023


If you wish to have less of an undesirable thing, then the prudent course of action is to study its causes and then work methodically to mitigate or eliminate them. Hospitals conduct morbidity and mortality conferences when things go wrong for their patients. Coaches review the game films from their losses. Toyota popularized the "Five Whys" technique at performing root-cause analysis on manufacturing defects. ■ The methods may vary, but the shared point is the commitment to uncovering the causes of undesired outcomes so that they can be addressed. And when done thoroughly and professionally, the process can have significant effects. It should be a matter of considerable pride, for instance, that commercial air travel has become radically safe by comparison with other means of transportation. Improvements in air safety are at least partly attributable to the investigatory work of the NTSB. ■ The National Transportation Safety Board exists to seek out the root causes of transportation incidents so that they, too, can be eliminated. It is crucial to note that the NTSB "has no authority to regulate, fund, or be directly involved in the operation of any mode of transportation". Its mission is strictly to investigate and make recommendations, entirely independent of any other agency of government. ■ The Fifth Amendment says that "No person shall [...] be deprived of life, liberty, or property, without due process of law". Yet hundreds of people are killed by police in the United States each year. In some cases, there is little doubt that the actions of law enforcement were necessary and prudent: A man firing a rifle inside a Target store is a clear and present danger to others, and swift action is plainly justified. ■ But other cases -- like the killings of Breonna Taylor or Botham Jean -- are different entirely. In general, it should be uncontroversial to believe that as few people as possible should die in the process of law enforcement, on either side of a badge. ■ If anyone at the Federal level of government were truly serious about reducing the number of civilians killed by police, then they would work to stand up an NTSB-style agency to investigate deaths involving law enforcement. Such an agency would need to be invested strictly with investigatory powers, not prosecutorial ones. It would need to be independent and professional, working solely for the purpose of investigating the incidents and uncovering the causes so that preventable deaths could be eliminated. ■ If politicians at the national level aren't trying to advance the policies that could do something about fixing root causes, then they probably aren't serious about the problem. The basic premise of the Fifth Amendment is clear: The right to one's own life is precious and sacred. Even when a perpetrator is killed under thoroughly justifiable conditions, it remains prudent to investigate how events unfolded as they did and whether anything could have gone differently. The NTSB model has proven itself to the traveling public. It's a model worth duplicating in the line of duty.

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