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There is a thing that happens in aviation after something goes wrong, and Naomi had spent the better part of a decade teaching it to twenty-three-year-olds in the Guard. You do not start with who. Who is the easy question and it is almost always the least useful one. If you start with who, you find a person to blame, and you punish that person, and you feel better, and six months later somebody else makes the exact same mistake in the exact same airplane because nothing about the airplane or the procedure or the training or the culture has changed.
You start with what happened. Then how. Then why, and then why again, and then why again, five or six layers down, until you reach the thing that would have let any reasonably well-meaning person make the same error. That is the root cause. That is what you fix.
But, she always told the young aircrew, leaning on the podium at the front of the windowless room, listen to me, because this is the part people forget. Just culture is not no-fault culture. Root cause does not mean nobody is responsible. If a pilot knowingly busts minimums because he wants to get home for dinner, the system is not the only thing at fault. That pilot does not keep flying until he has been retrained, and if he does it again he does not fly at all. You hold the system accountable and you hold the person accountable, both, and you do not let one of them hide behind the other.
She wrote at the top of the page: WHAT. HOW. WHY. WHO.
Under WHAT she wrote: Officer grabbed my arm from behind, without verbal warning, before asking a single question. Detained me on the ground, then in handcuffs, for approximately eighty minutes. Basis: my presence at my own car. Secondary basis: a forty-seven-year-old stolen vehicle record that should not exist.
Under HOW she wrote a list.
Bodycam. Was it on? When did it start? Most departments use cameras with a pre-event buffer that records video without sound for some period before activation. Request all footage, including buffer.
Dispatch audio, CAD log, Lot E security cameras (airport-owned; request before overwrite), Hector's video.
Odette. Jasmine? (Only if she wants to. Ask Odette.)
The legacy record. Who entered it. When. On whose complaint. Why it was never cleared. How it survived a migration. How many others there are.
Under WHY she wrote: Briefing about thefts in Lot E? What were officers told to look for? Who decides what "suspicious" means?
Under WHO she wrote only one word, and underlined it, and then put a question mark after it. Brandt?