{
  "schema": "vedokrok.public-item.v1",
  "release_id": "MHC-RPUB-20260920-75ad787a",
  "url": "/knowledge/review-exception-debt-as-a-portfolio",
  "id": "MHC-D-RESEARCH-1277",
  "version": "0.1.0",
  "title": "Review exception debt as a portfolio",
  "summary": "Ten small exceptions can create one large operating mode nobody intentionally designed.",
  "kind": "protocol",
  "body": "Periodically review active exceptions together, not only one at a time. Look for shared controls that several exceptions weaken, repeated reasons that reveal a structural defect, interactions between exceptions and old items that have outlived their context. Close, redesign or consolidate them. The objective is to prevent local accommodations from composing into an unreviewed system state.",
  "limits": [
    "A portfolio view is editorial systems reasoning based on temporary-change and normalization principles; it is not a claim that every collection of exceptions is unsafe."
  ],
  "topics": [
    "union-drift-alerts-change-control"
  ],
  "intents": [],
  "source_ids": [
    "RS-51C347036C655252",
    "RS-2B07FFA4A53D551C"
  ],
  "evidence": [
    {
      "claim": "NASA describes normalization of deviance as a gradual shift in which unacceptable practices or standards become accepted after repetition without catastrophic results.",
      "source_id": "RS-51C347036C655252",
      "role": "supports",
      "note": "The concept explains one organizational failure pattern; it does not prove that every local deviation is unsafe.",
      "locator": "Abstract and Appendix B theme 6"
    },
    {
      "claim": "OSHA process-safety guidance recommends identifying and reviewing changes before implementation and specifically says temporary changes need a monitored time limit because uncontrolled temporary changes can become permanent.",
      "source_id": "RS-2B07FFA4A53D551C",
      "role": "supports",
      "note": "The guidance is written for hazardous industrial processes; the general exception-control pattern is transferred here by analogy.",
      "locator": "Managing Change"
    }
  ],
  "use_when": [
    "A system has accumulated several individually reasonable exceptions, waivers, manual bypasses or temporary controls."
  ],
  "avoid_when": [
    "A portfolio view is editorial systems reasoning based on temporary-change and normalization principles; it is not a claim that every collection of exceptions is unsafe."
  ],
  "example": "Three teams each have a temporary manual approval bypass for different reasons. Viewed together, all three remove the same independent review layer and deserve one system-level decision.",
  "check": "The review can describe the combined control state created by the active exceptions, not merely justify each exception in isolation.",
  "steps": [
    "List all active consequential exceptions and their owners.",
    "Group exceptions that weaken the same control or depend on the same manual step.",
    "Flag expired, repeatedly renewed or ownerless items.",
    "Look for one underlying design problem creating multiple exceptions.",
    "Close, redesign, or formally approve the resulting operating state."
  ],
  "sources": [
    {
      "id": "RS-51C347036C655252",
      "title": "Best Practices for Organizational Resilience in the International Space Station (ISS) Program",
      "url": "https://ntrs.nasa.gov/citations/20250005960"
    },
    {
      "id": "RS-2B07FFA4A53D551C",
      "title": "Compliance Guidelines and Recommendations for Process Safety Management",
      "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1926/1926.64AppC"
    }
  ],
  "relations": [],
  "collections": [
    {
      "id": "RC-63301F6643A9DBC3",
      "title": "Detect safety drift before the exception becomes normal",
      "url": "/collections/detect-safety-drift-before-the-exception-becomes-normal"
    }
  ]
}