The contrast between two transportation accidents (Southern Pacific 7551 and US Airways 1549) provide the background required to understand what a quality culture means in complex services. Rigorous training and enforcement of well thought-out and shared rules combines with freedom to act to produce the best outcome when experts are faced with unforeseen circumstances. On the other hand, a « good enough » quality culture slowly takes hold as sloppy work without immediate consequence is tolerated. The silo mindset hides the potentially devastating systemic effect of these defects.
