One of the footnotes is worth pondering at great length:
I’ve spent a lot of time asking about why things are the way they are, both in areas where things are working well, and in areas where things are going badly. Where things are going badly, everyone has ideas. But where things are going well, as in the small company with the light-touch CEO mentioned above, almost no one has any idea why things work. It’s magic. If you ask, people will literally tell you that it seems really similar to some other place they’ve worked, except that things are magically good instead of being terrible for reasons they don’t understand.
It’s remarkably easy to complain and point out the bad things. It also gets most of the attention (“if it bleeds, it leads”). But it’s even easier to dismiss the good things and assume that by simply not doing bad things, good outcomes are inevitable.
Further reading on the normalization of deviance.
Furthermore, it is especially striking how multiple
rule violations and lapses can coalesce so as to
enable a disaster’s occurrence.
Often phrased as “a disaster doesn’t just happen, you’ve got to work at it”