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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