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We know how to get better. We have a model. (several!) Airline crash investigation, medical training. These all show we can extract best practise and identif

We know how to get better. We have a model. (several!) Airline crash investigation, medical training. These all show we can extract best practise and identify improvements. Have open reviews on everything. How did that year long project go? Was it properly thought out in first place? we're expectations matched with funding? We can improve. Edit: (Good) Journalism is a rough proxy for this mechanism - and one could make a case for countries that have better free press have better results (and that's not just limited to dictatorships - compare say US press to say Norway). Anyway - why do we leave such an important jobs to haphazard civilian publishers ?

banannaise 6y ago
The operative problem is that usually the primary output of an investigation is blame, and the primary method of improvement is punishing the people who are to blame. It's retributive justice as process improvement, and that's directly at odds with proper root cause analysis and process improvement.
- lifeisstillgood 6y ago
  Which is why air crash investigations are a good model - they don't often blame the pilots (solely) and have the force to implement fixes (mostly because federal agencies have sway over Boeing and the large US market). But it has worked well for a very long time even if 737-Max suggests it's weakening.