As you say, the fascinating part about these accidents is that the risk was informed. There's a tendency to simply say "If we had more procedures, and they wer

As you say, the fascinating part about these accidents is that the risk was informed. There's a tendency to simply say "If we had more procedures, and they were followed, then this wouldn't have happened." But that seems like a dodge. More often than not (in my experience), more procedure is simply seen as overly-burdensome and actively subverted by users (in the service of laziness, performance, compensation, or deadlines). As you say, willfully making bad decisions for bad reasons. Sometimes you have the benefit of almost absolute control over people, e.g. SUBSAFE [1] (or Navy or Air Force maintenance QA programs). But most organizations don't have that kind of training budget. Consequently, the most effective procedure is the safest one that people will actually follow. So strike that balance. [1] If you can get a hold of high-level documentation, an excellent example of error mitigation in practice -- https://en.wikipedia.org/wiki/SUBSAFE https://en.wikipedia.org/wiki/SUBSAFE