Quote Kharon:
"Some -Kaizen-style analysis of the organisational pressure-build-up might be highly enlightening.
Kaizen will only work when and where 'it's wanted'. Like all curses if the 'malady' is not identified a cure cannot be found. Once identified, both malady and cure: the patient must be willing to undergo the treatment; if the cure is to be effective. Our sick tiger presents with two main symptoms, which manifest through several other symbiotic ailments.
I think it's true to say ANY process to identify root cause and propose a workable solution will be welcome only when it is wanted. As far as Kaizen goes (which is quite a long way) there needs to be that all-important root cause identification. Accomplishable through the
"5 Whys" process. The process isn't just to inform the diagnostician, it's carried out to get the patient to accept the reality of the problem, too.
Two ways to do this: Tiger calls in someone independent (like the Sleuth in Kharon's post, above?) who tells them what's wrong and how to fix it, or they ignore the problem until it manifests itself through an event that require an ATSB investigation and THEN they face the music - in a public forum.
One of these paths is the strategy of least regret. I wonder which they will choose?