ABSTRACT
Instead of an environment that leads to a breakdown of the importance of safety in a systems engineering methodology, management must establish feedback loops of audits and performance assessments, reporting systems, and anomaly, incident, and accident investigation. The term “lessons learned” must be part of the tailoring process. Lessons learned must help to escalate identified safety issues or incidents from a rote exercise to an opportunity to teach a method of systemic and programmatic improvement throughout a life cycle.
