In case your interested:
https://skybrary.aero/articles/james-reason-hf-model
Unfortunately, I’ve seen it live and in color in all it’s glory....more than once.
I’m in engineering and I see management and business personnel create systemic failure too often.
MBAs only looking at the current fiscal quarter, with no long term sight, is mind boggling. By the time the failure occurs, the managers and MBAs have played corporate musical chairs.
Thanks for the link.