The example that makes this session concrete comes from medicine: a nurse who sees a physician about to administer the wrong medication and, in an environment where speaking up carries risk, does not. Nothing about the nurse's competence was the failure — the information existed in the room and did not move. Security work makes this worse, because the cost of a missed signal is delayed and the person who spots it is often junior to the person who would be contradicted. The anxiety zone described — real pressure to deliver with no safety to contribute — is a fair description of an organisation during an incident, which is exactly when information most needs to travel. The four-stage model localises the failure so a leader can tell which intervention is needed, and the reframing of reversible decisions separates mistakes that deserve a penalty from those that do not.
