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The recurring pattern following major incidents: acknowledgement of harm → formal commitment to 'never again' → establishment of reviews/taskforces → publication of recommendations → gradual reversion to pre-incident conditions. Recurrence is common because binding architecture is absent.
Following a safety failure, an organisation commissions inquiry, implements reforms, declares problem solved. Within 18 months, reforms erode and similar failures recur—the commitment governed narrative, not operations.
CEA-App Section 4.1