When you treat every negative outcome as a system failure, the answer is more systems. This is the cost of a blameless culture. There are places where that’s the right answer, especially where a skilled operator is required to operate in an environment beyond their control and deal with emergent problems in short order. Aviation, surgery. Different situations where the cost of failure is lower can afford to operate without the cost of bureaucratic compliance, but often they don’t even nudge the slider towards personal responsibility and it stays at “fully blameless.”
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