Eradication of all latent failures is limited primarily by economic cost but also because it is difficult before the fact to see how such failures might contribute to an accident. The failures change constantly because of changing technology, work organization, and efforts to eradicate failures.

…

Indeed, it is the linking of these causes together that creates the circumstances required for the accident. Thus, no isolation of the ‘root cause’ of an accident is possible. The evaluations based on such reasoning as ‘root cause’ do not reflect a technical understanding of the nature of failure but rather the social, cultural need to blame specific, localized forces or events for outcomes.

…

Hindsight bias remains the primary obstacle to accident investigation, especially when expert human performance is involved.

So many more nuggets of wisdom in there.

Esther Derby:

Clarity enables patterns of coherent action across the organization. Contextual understanding supports initiative–people don’t have to wait to be told what to do. It speeds Decision Making as people closer to the work have the information to make more decisions in a reasonable way. Clarity reduces the need for supervision.

…

Smoothing the flow of work, organizing work and teams to reduce dependencies and handoffs, is management work.

James Clear:

In my opinion, this is the greatest success “hack” there is. If you live in an environment that nudges you toward the right decision and if you surround yourself with people who make your new behavior seem normal, then you’ll find success is almost an afterthought.

Systems are better than goals.