In a 5Ys/RCA process, I always make it a point to focus on process failures pretty much exclusively… except when there’s malfeasance, negligence, or outright incompetence involved. This situation seems like one of those exceptional instances.
But there were clearly some process failures as well.
I find it funny that nobody (including the article) is discussing the chance that it’s straight up incompetence.
Yeah, this is a very good point too. Where’s the peer review on something that is so critical!?
In a 5Ys/RCA process, I always make it a point to focus on process failures pretty much exclusively… except when there’s malfeasance, negligence, or outright incompetence involved. This situation seems like one of those exceptional instances.
But there were clearly some process failures as well.