That's happened before, and it was fine.
Warning signs get filed as normal
The team sees the problem, discusses it, and decides it's acceptable because nothing bad has happened yet. Each time it happens without an obvious consequence, it becomes easier to treat as normal, until it's just part of how things are.
- A list of known issues nobody looks at anymore.
- A recurring problem gets explained away with "it's always like that."
- Alerts that people have learned to ignore.
Who: two people who have worked on this workflow for more than a year. Ask: "What do we see regularly that would have worried us the first time we saw it?" For each answer, ask: "When did we first see it, and why did we decide it was acceptable?" You're probably looking at this pattern if they name problems that became normal only because nothing bad happened. Probably not if each accepted problem has a clear reason it's safe.
Workarounds the system never learns from. In that pattern, the problem was patched quietly and never reported. In this pattern, it was reported and then accepted.
Ask, "What do we see regularly that would have alarmed us the first time we saw it?"
Create one shared, blame-free place to write down what almost happened and what caught it.
Sociologist Diane Vaughan found that the engineers and managers behind the 1986 Challenger launch had come to accept damage to the booster seals one decision at a time. The board that investigated the loss of Columbia in 2003 found the same pattern with foam striking the shuttle. Established pattern, from detailed case studies. A 2023 review found 33 papers on the idea, and only 7 collected new data (Sedlar and colleagues, 2023).