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[[circled]] 3 [[circled]] Accidents I was [[?]] BDS Failed leadership at many levels [[?]] to a culture ripe for failure [[bulletpoint]] inattention to detail (smallest mistake) [[left margin]] decisions not to test to extremes [[/left margin]] [[bulletpoint]] easing/waiving of standards (insidious, subconscious) -> MGMT didn't promote culture that encouraged comm + allowed surfacing (+ [[?]] eval) of problems "Normalization of Deviance" [[bulletpoint]] saw problems (nothing bad happened got away with it [[bulletpoint]] sol'n less urgent [[bulletpoint]] approached "normal" Led to sig. underest, or ignore, risk Learned [[bulletpoint]] improvement, change req commit. from top [[bulletpoint]] requires continued commitment so message + culture spreads through org -> motivate, develop, encourages, RESEARCH? REC ? [[?]]
Transcription Notes:
-Easing not ending standards
-comm + not 't'
- (+ [[?]] eval
Guessing at last 2 enties