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Because overt failures are rare, a quiet period follows Institution of these new policies, convincing administrators that the changes have been effective.
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When a new overt failure occurs, it seems to be unique and unconnected to prior failures (except In the label human am), and the cycle repeats.
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With each pass through the cycle, more rules, policies, and sanctions make the system more complicated, conflicted, and brittle, increasing the opportunities for latent failures to contribute to disasters.
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