> After accident reviews nearly always note that the system has a history of prior ‘proto-accidents’ that nearly generated catastrophe. Arguments that these degraded conditions should have been recognized before the overt accident are usually predicated on naïve notions of system performance.
What does that mean? If you knew that the precursors were why did you not set alerts?
What does that mean? If you knew that the precursors were why did you not set alerts?