A Catch in Time

This article reviews one principle that holds true across two centuries of human experience. Instead, little malfunctions and errors link up beforehand, over weeks and months. Usually, these are early warning signs, called precursors, that offer time for those at the scene to stop the chain of events. Catching system fractures happens in several stages. Alert employees notice early problems. They decide that the potential problem is serious and that preventing a disaster will need management support. In organizations like Southwest Airlines and Naval Reactors, some employees have shown that safety, excellence, and production can all fit together. For the rest of us who are not quite there yet, good fracture awareness—among front line employees as well as top decision makers—is an important step in that direction.