Comment by woopsn

The referenced "researcher/guru" Sidney Dekker wrote a whole book titled Drift Into Failure. "Accidents come from relationships, not broken parts."

"Safety may not at all be the result of decisions that were or were not made, but rather an underlying stochastic variation that hinges on a host of other factors, many not easily within the control of those who engage in fine-tuning processes. Empirical success, in other words, is no proof of safety. Past success does not guarantee future safety. Murphy's law is wrong: everything that can go wrong usually goes right, and then we draw the wrong conclusion."

"Why, in hindsight, do all all these other parts (in the regulations, the manufacturer, the airline, the maintenance facility, the technician, the pilots) appear suddenly "broken" now? How is it that a maintenance program which, in concert with other programs like it never revealed any fatigue failures or fatigue damage after 95 million flight hours, suddenly became "deficient"? Why did none of these deficiencies strike anybody as deficiencies at the time?"

The central idea is not to (stop at) discovering what mistakes were made, but to understand why they didn't seem like mistakes to the individuals making them, and what suppressed the influence of anyone who might have warned otherwise.