ABSTRACT
How could it have made sense for the pilot to continue his approach despite (what we now know to have been) increasingly bad weather? How could the shift operator have missed the valve setting that, in hindsight, appeared so obviously necessary? How could it have made sense for the surgeon to revert to an open procedure despite (what we now know as) indications that this would be more dangerous for the patient than the laparoscopic one? Forensic human factors experts can be called on to make sense out of such puzzling performances.
