> I hope the people responsible for this disaster, their managers and the QA team were fired. This is a actually a rather typical response, made with full awar

> I hope the people responsible for this disaster, their managers and the QA team were fired. This is a actually a rather typical response, made with full awareness of the consequences of an action by people not under the same constraints as the participants in an incident. Diane Vaughan (an expert on risk, causes of incidents, and how organizations come to become error-prone) terms these actions 'ritualistic': > Causes must be identified, and in order to move forward, the organization must appear to have resolved the problem. The direct benefit of identifying the cause of an accident as Operator Error is that the individual operator is the target of change. The responsible party can be transferred, demoted, retrained, or fired, all of which obscure flaws in the organization that may have contributed to the mistakes made by the individual who is making judgments about risk. The dark side of this ritualistic practice is that organizational and institutional sources of risk and error are not systematically subject either to investigation or other technologies of control. To make it even better, you're now throwing away all the people most experienced in the conditions that lead to a specific incident. Unless very specific conditions are true, this is a sub-optimal recommendation. The evidence seems to be against building a culture of fear.