It’s an inescapable fact that the causation of seriously harmful events in project management and product development includes multiple missed opportunities for multiple ordinary people, organizations, and groups to have prevented the harm entirely or to have greatly reduced it by doing ordinary things ordinarily well.
Abstracted from the tagline of the Firebird Forum a Root Cause Analysis community I belong to, focused on RCA mostly in the nuclear power business, but applicable to our software-intensive system of systems domain, where those SW systems are embedded in emergency shutdown and process control domain
