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It reminds me of the NTSB's crash investigations. Instead of looking for a scapegoat or someone to blame, they look for the cause, and then look even deeper to find the root cause.

For example they discover a pilot made a mistake. But they don't end it there, they then look at the airline's training materials, see if other pilots would repeat the same mistakes, and so on until they reach a point where they have a "this won't happen again" resolution (rather than simply discovering what happened).

I feel like with Microsoft's breakdown they did the "this is what happened" post-mortem but then went to the next level and said "here's why this happened, and here is why it won't happen again."




Nitpick: Crash investigations are done by the NTSB, not the FAA.

The NTSB has no authority to enforce its recommendations. That's up to the FAA. The idea behind that is the NTSB is more likely to be impartial.


Valid correction. I've edited it in. But it did originally say FAA, not NTSB.




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