If a machine stops working, we don’t stop the analysis when we discover a broken part. Instead, we ask: “Why did the part break? Was it an inferior part? Were the required specifications too low? Did something apply too high a load on the part?” We keep asking questions until we are satisfied that we understand the reasons for the failure: then we set out to remedy them. We should do the same thing when we find human error: We should discover what led to the error. When root cause analysis discovers a human error in the chain, its work has just begun: now we apply the analysis to understand
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