The purpose of the Operational Excellence Case Study program is to help you recognize where human and organizational errors occur in the workplace. The events are real. We have tried to identify the active errors or latent conditions that were in place to understand what did not go right. We may not identify all contributing causes but it is not the purpose of these case studies to re-investigate past events only to use them as learning tools. As you read and discuss these case studies, place yourself in a similar position; what tools are available to you that could help spot the error precursors.