> human error is an unfortunately effective way at ending an investigation If you can't find a scapegoat, senior executives will line up to throw themselves

> human error is an unfortunately effective way at ending an investigation If you can't find a scapegoat, senior executives will line up to throw themselves on a grenade in return for a golden parachute and preferential place at the revolving door of professional management networks. Why? Because the kind of contextual root cause analysis the author is (in good faith) promoting here is the last thing anybody wants in companies that cut corners and push risk externalities on to the world. > we human beings are physical beings, you can think of us as machines Nice postulate let's see where that leads... It's certainly dehumanising (and therefore fails multiple essential requirements for real-world use) but let's entertain the idea that we are simply little functional utility maximisers. > how did the operator's g function score a higher value for pushing A over B? All we have to do is take into account every single variable and contextual factor of the workplace, training, remuneration, budgets, policy, corporate strategy, markets, competition... But there's a fly in the ointment. Are corporations not "legal persons"? So we must also consider them "as machines", right? They cannot be 'blamed', but are merely little profit maximising functional automatons. And by dint of the same logic, we must look to their environment, contextual variables, national and global politics and so on, in which governments are simply little utility maximising machines with their own values. While not an infinite regress, it is an analytic process that pushes all causation out to a nebulous margin which, most importantly, cannot be changed. Therefore all failures, no matter how many lives or billions of dollars are lost, is ultimately "just the way the world is". In our hearts most of us already know this. But perfomative justice, and the entire edifice of rational scientific management, rests on finding local culprits after no more than "5 why?" iterations.