"In other words, assume that everybody whose actions contributed to the incident made the best possible decision based on the information they had, and the constraints and incentives that were imposed upon them."
https://surfingcomplexity.blog/2024/02/17/what-if-everybody-did-everything-right
Mastodon Source 🐘
Another way I've backed into this is to investigate events that do not produce undesirable outcomes.
A successful deployment is often the default assumption, although what constitutes "success" is usually fluid. How much work is required to sustain the non-event? Are there things people are doing that they already recognize as "risky" but are also "normal"? What's the collective effort to maintain the illusion of stability?
Today's "normal" behaviors are tomorrow's "faulty deviations" .