But the process doesn't seem to help if the fundamental reasons for it aren't understood or are ignored, and if the devotion to process just creates new processes whereby anomalies are just documented and fed into the system to become a normal part of procedure. How many pairs of eyes looked at the O-ring and foam strike problems? What did they do? They documented it, drew graphs and presentations, and pronounced it as A-okay. Just add O-ring and chipped tile replacement to the workflow diagrams! It didn't work and everybody died.