"Organizations treat coordination failures as individual mistakes.
Six months from now, the write-up will read like inevitability. In a reliability improvement that shifts risk elsewhere, every step on the way will have sounded reasonable. That is how drift stays invisible.
In a reliability improvement that shifts risk elsewhere, the shortcut will be framed as temporary. Temporary decisions have a way of turning into the operating mode, especially when they make next week easier. You see it in fixes that add paperwork instead of improving detection and containment. Write it down because otherwise two reasonable engineers will execute two different interpretations, and the system will call it “miscommunication.”
Diane Vaughan is a reminder to audit the argument, not the intention. From six months ahead, name the failure and the excuse, then insist on one backstop. Save it where decisions live.