Yes, I know. But “never” means zero. Aviation death risk is extremely low (esp. for commercial scheduled passenger), but about 100x less complex, lower demand/pressure, better resourced, and less messy generally (not starting with a sick airplane).
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‘Fixes that fail’ - very common in social systems. https://en.m.wikipedia.org/wiki/Fixes_that_fail … It sounds to me like some protected time and space is needed to apply some restorative justice.
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We certainly need something. Not sure that Wikipedia definition is ideal for this situation? Seems to describe a fix that starts out working, but later fails? This fix never worked - as intended.
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Problem, as with checklists, is failure in implementation. Inadequate analysis of context and how a fix affects (or does not account for) the context to create secondary problems or just embed problem further.
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Like Plan-Do-Study-Act cycles...often forgotten that this is only implementation phase. Study-Plan-Do cycle would be simpler, work better, and remind everyone to study the problem situation and context deeply first, from multiple perspectives.
End of conversation
New conversation -
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