Finding Better Procedures

Fear sparked those emotions during the Air Force incident, and no wonder. Nuclear weapons are serious business, and theft is a very real concern. But the subsequent incident investigation found that the people involved did not intend to fly live warheads over the United States. According to some reports, ground crews handling the warheads came up with informal procedures of their own.

This, in fact, is where stopping a Cause Map at Procedure Not Followed misses a golden opportunity. Technicians closest to the incident often develop informal procedures that make their lives easier (following the sometimes unfortunate maxim, It's better to apologize than to ask permission.) This can be a terrible thing in critical and dangerous work, such as working with fissile material in the hills of North Dakota. But in some instances, uncovering the details behind these informal, albeit imperfect, processes can lead to a discussion that ultimately creates a better, formalized work process.