
The author explains what he believes managers have been doing wrong, informs them what they must do, and shows them Demings' Way Out of the crisis.
as an aside: two books that made it almost impossible for me to deal with management "goals" at large corporations anymore:
1. the goal - by goldratt
2. out of the crisis - by deming
highly recommended!
Systems do not have to facilitate operators in building accurate mental models. In fact, safe systems disregard mental models, because a mental model is a human thing, and humans are fallible. Remove the human and you have a safer system.
Safety is not a dynamic control problem, it's a quality-state management problem. You need to maintain a state of quality assurance/quality control to ensure safety. When it falters, so does safety. Dynamism is sometimes not a factor (although when it is, it's typically a harmful factor).
Also fwiw, there's often not a root cause, but instead multiple causes (or coincidental states). For getting better at tracking down causes of failures (and preventing them), I recommend learning the Toyota Production System, then reading Out Of The Crisis. That'll kickstart your brain enough to be more effective than 99.99% of people.
Instead of creating a digital whip for shallow (or even outright harmful) managers, they could have developed a QA tool grounded in real, deep thinking—one that respects proven principles of manufacturing.
There’s still time to course-correct, and embracing some of the foundational literature on the topic could make the difference.