Exactly arranfan
I work in an industry where risk assessment is used a lot. I bang on ENDLESSLY about system failures and how they arise. People fuck up. they fuck up accidentally, they fuck up with good intent and with bad, they fuck up deliberately sometimes. You cannot stop that, humans are fallible. Always will be. You can reduce it but you can’t stop it.
But what you CAN do is put systems in place that recognise human fallibility, whether innocent or not, and which throw up checks and barriers to protect the system.
You can also create an institutional atmosphere that either stifles or exposes errors. I’ve worked places where CAPA analysis (root cause analysis) has been used and in one place it was changed from no fault (ie bring me your faults and fuck ups without fear of retribution, because we can learn from them) to one where it was used against people. Result? Within six months we had critical system failures because no one was bringing us faults to correct, they were trying to cover them up.
This whole affair shows failure at every level, from individuals to groups to the very culture of the party itself and society at large. It’s incredibly disturbing.