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In aviation, we call that the "swiss cheese model". There are holes distributed within it, and accidents happen when all the holes are aligned.

The corollary is that you must fix the holes as soon as you find them, so they won't all align in your path. And you do find the problems before a disaster, but people don't like to fix things.

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Some people do, but most are worried they'll be blamed for either the fact that the problem exists in the first place (complainers, criticizers), for rocking the boat (whistleblowers, trouble-makers), or for fixing it wrong (stupid, careless). Our system, or many, for that matter, isn't set up to reward people who find and fix holes.

That all said, there are exceptions. But pettiness and self-centeredness can so often wreck it, or at least deter people from being bold enough to face judgment or possible error in order to do the right thing.

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