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Managing the Unexpected: Sustained Performance in a Complex World, 3rd Edition by Kathleen M. Sutcliffe, Karl E. Weick

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Chapter 9Sustaining Sustained Performance

“Human error is not a distinct category of human performance. After the outcome is clear, any attribution of error is a social and psychological judgment process, not a narrow, purely technical or objective analysis.”1

—Richard I. Cook and David D. Woods

“Reliability is not bankable, nor contingent on how many failure-free performances lie behind.”2

—Paul R. Schulman

“In a world of unexpected events the capability to make sense out of an emerging pattern is just as crucial as a highly refined system of decision making.”3

—Karl E. Weick, Kathleen M. Sutcliffe, and David Obstfeld

Here's the scene. It's December 2, 1984, at 11:30 PM, shortly before at least 3,800 people will die from a leak of a toxic ...

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