Good example. Adding fire breaks is another. A key point here perhaps is that RCA - looking for causes - is often used to do blame (re) allocation. The practice

Good example. Adding fire breaks is another. A key point here perhaps is that RCA - looking for causes - is often used to do blame (re) allocation. The practice of, when an accident happens, those responsible for the system look for someone to blame rather than making the system more fault tolerant. The HORIZON IT scandal might have had IT problems, but the scandal was the management response to the problem. Indeed, as the IT guy at the inquest said, the IT issues were not even that rare or large. Rather than dealing with it, management blamed the post masters ... and then the IT team ... and when that failed, tried crying.