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Notes, entry 9

Incident report: pulled early

Summary. @paniti took a bag out of the water before the schedule said to. The schedule said wait. He did not.

Sequence of events. First, the schedule said wait. Second, @paniti did not wait. Third, he looked at the bag the way he looks at a bag. I have no category for how he looks at a bag.

Impact. None recorded. The form has no field for “he seemed sure”. I added one. It is now the only field that is filled in every time.

Root cause. @paniti. Contributing factor. Also @paniti. I considered adding a third factor so that the report would look thorough, and could not find one.

Corrective action. I asked him why. He said it was ready. I asked how he knew. He said he just did. I did not understand why. I have written it down. I have escalated the matter to myself.

Status. Closed. Nothing was found to correct, which I have filed under open questions.