> "What happens when requirements change inside the launch window?" > "The alert fired but..."

In the running example I think it is clear that you could stop at any point and address the problem from that point rather than continuing. Questions such as "Why do we permit last minute changes at all?" are given no space.

In a complex system sometimes there is no root cause (cf. aviation crash investigations and the Swiss Cheese nature of risk). By allowing one person to shoulder the entire context of the incident and for that person be the one to suggest lasting corrective actions it leaves little need for the VP to even be involved. How would they know if the proposed corrections are worth the time and money to implement? I don't see any leadership in the example described in the article - I just see a knee-jerk reaction rather than any kind of proactive reflection.

> "I thought we fixed this last time!?"

> "This time was different in a way that our corrective actions didn't address."