“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 ...