The basis and premise for this chapter is best explained by relaying a true account of a revolutionary experience I had many years ago. At the time, I was the Director of Safety for a large international on-demand aviation operator. one of our regional operators experienced three catastrophic accidents within a six-month period. It was after the third accident that the Ceo ordered an operational standdown and full internal audit. The boss directed me to assemble and lead the audit team that consisted of several subject-matter experts from our corporate office and the field. Included were operations specialists, maintenance experts, ramp support personnel and, of course, me. I contacted the regional manager in charge of the operation and informed him of our arrival date and intentions for the audit. I was immediately troubled when he didn’t seem to think the audit was necessary, nor was it a big deal. He was more concerned about getting us in and out so he could resume operations. The morning we arrived, I scheduled a desk-side in-brief for him intended to further explain and provide more details about the audit. To put it mildly, the briefing did not go well for me. I barely got a word in edgewise as he explained to me that I had about one or two days to complete the audit and get out of his hair. He further went on to explain that he had already conducted his own internal audit and determined that each of the catastrophic accidents were totally unrelated, coincidental, and in no way connected to one common denominator or causal factor. I politely listened to his brief and secured his agreement to begin my audit immediately so we could wrap it up and get on our way.