"The point of an investigation is not to find where people went wrong; it is to understand why their assessments and actions made sense at the time."
"... made sense at the time" to whom? The investigation might want to look at whether what went wrong should have ever made sense to anyone -- what were they thinking?! -- and why someone was allowed to think it ever made sense.
I have in mind the Challenger accident of the mid-space shuttle era. Should anyone have been allowed to think that the solid boosters were safe after overnight temperatures in the 'teens? In that case the mix of politics, management, and engineering proved deadly.
Just released! The second edition .........
Bookmark this on Delicious
Read in the library at Square Peg Consulting about these books I've written
Buy them at any online book retailer!
Read my contribution to the Flashblog