ABSTRACT
Most investigations are carried out after an event has occurred. But the search to reduce opportunities for error should be ongoing, even in the absence of an accident. System managers, administrators, operators, regulators, and others involved in operating complex systems need to be vigilant in the search for system deficiencies that could lead to errors and accidents. The potential for unknown and unrecognized antecedents to error residing in systems is too great to allow regulators, companies, and operators to become complacent about the safety of their systems. Avoiding such views and remaining on guard to identify and mitigate error antecedents is proactive and in the best interests of safety.
