Comment by Propelloni

It is like in organisational error management (aka. error culture), there are three levels here:

1) errors happen, basically accidents.

2) errors are made, wrong or unexpected result for different intention.

3) errors are caused, the error case is the intended outcome. This is where "bad people" dwell.

Knowing and keeping silent about 1) and 2) makes any error 3). I think, we are on 2) in TFA. This needs to be addressed, most obviously through system change, esp. if actors seem to act rationally in the system (as the authors do) with broken outcomes.