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in 99 words
When mistakes occur, blame your process, not people. Root-cause analysis helps. What allowed the mistake to happen? What will prevent them in the future? Assume people will continue to make mistakes and build fault-tolerance into your improvements.
One approach: ask "why" five times. Use it for every problem you encounter, from the trivial to the significant. You can apply some solutions yourself. Some will require team discussion, and others need coordination with the larger organization.
When mistakes become rare, avoid over-applying root-cause analysis. Balance the risk of error against the cost of more process overhead.
as haiku
a slug eats dessert...
making lattice from lettuce,
she thins the surplus
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In the Privacy of Your Own Thoughts
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