Category Archives: Incident Analysis

The Baldwin Killing (Part I)

By tacticalprofessor on | 7 Comments

Since I’ve been asked several times my opinion about the Baldwin Killing, I’ll address those questions from the perspective of firearms safety only. The incident is a high profile example of a Serious Mistake leading to a Negative Outcome. Such a tragic event bears analysis to see what are the lessons that can be learned to prevent other such incidents, either on a movie set or in our personal lives, in the future.

For those who haven’t read the news lately, actor Alec Baldwin unintentionally discharged a revolver on a movie set last week. https://www.independent.co.uk/arts-entertainment/films/news/alec-baldwin-shooting-halyna-hutchins-latest-b1945263.html The film’s Cinematographer was killed by a single bullet that struck her in the torso and the Director was injured. RIP Ms. Hutchins.

Those who are interested in a legal aspects of the case can find my colleague Andrew Branca’s initial legal analysis on YouTube. https://youtu.be/upDuj8Ec Such an analysis is out of my league, so I will stay in my own lane and confine my comments to safety.

What occurred points out a very simple fact of life:

Firearms, like electricity, are relentlessly unforgiving of the slightest lapse in attention

The Tactical Professor

One of the slides in the NRA Basics of Pistol Shooting Course states that Ignorance and Carelessness are the causes of firearms accidents.

NRA Training Department

The concept of ‘tolerance stackup’ often applies when an Unintentional Discharge occurs. By this we mean that when Ignorance and Carelessness overlap each other, the possibility of a Negative Outcome dramatically increases. Sadly for Ms. Hutchins, she was downrange when that overlap occurred.

A comment was made on an earlier version of Andrew’s video about the probability that the gun being used was a single action revolver. The commentator noted that the manual of arms of a single action is more complicated than a modern autoloading pistol. The extra steps involved in clearing a single action may have contributed to the discharge. For once, a comment was worth reading. Extra caution needs to be taken when handing firearms that have an unfamiliar and perhaps difficult manual of arms. That’s definitely a lesson that can be taken away from the incident.

There is no standard manual of arms that can be applied across all firearms, even modern ones. For instance, the Ruger LCP has a manual device for locking open the action but it does not lock open automatically. Conversely, the KelTec P-32 and P3AT do not have an external device to lock open the slide and require an empty magazine to do so. Despite the fact that the guns look very similar, they operate differently and require the operator to understand how to work them.

Another comment on the earlier Branca video came from a POlice firearms instructor who said there were at least 11 different firearms safety rules that have to be observed on any firearms range. While a case can be made for that argument, 11 or more rules constitutes a checklist that has to be written down. The need for long lists to be written down, i.e., a checklist, was learned in aviation somewhere around a century ago. While appropriate for range operators, and perhaps the film’s armorer, it’s not compatible with the way the human mind works. A memory aid has to be short, e.g., the Four Rules, or organized as an acronym, e.g., SALUTE.

The Four Rules of Safe Gunhandling are a good memory aid. However, we need to keep in mind that a memory aid is not a full explanation of the concepts being remembered, it is merely a way to jog our memories about what the base concepts are so we can apply them fully. The distinction between checklists, memory aids, and the concepts either are based on is another lesson we can take away from The Baldwin Killing.

“That could never happen to me” thinking is one reason I developed the underlying concepts contained in Serious Mistakes Gunowners Make http://seriousgunownermistakes.com years ago. I didn’t intend it for Hollywood actors but in retrospect, I wish the entire crew of the movie had read it. I’m not trying to be facetious or unkind to Ms. Hutchins’ memory by saying that.

More thoughts about The Baldwin Killing tomorrow.

Tactical Professor books (all PDF)

Purchase of any book includes Serious Mistakes Gunowners Make.

STOPP Presentation at Rangemaster Tactical Conference

https://tacticalprofessor.wordpress.com/2021/09/14/stopp-presentation-now-available/

https://www.payloadz.com/go?id=3381307

Posted in: Incident Analysis, Negative Outcomes, revolvers, Serious Mistakes

Intended Victim not ‘Subject’

By tacticalprofessor on | 2 Comments

The man did not know he was being followed according to police and once at the man’s home, [the shootee] allegedly produced a firearm and confronted the subject [sic] as he was trying to get out of his vehicle and go into his home.

https://wfxl.com/news/local/valdosta-shooting-ruled-self-defense

‘Subject,’ in POlice terms, is almost always used in the context of a wrong doer. In current times, the default treatment of anyone who shoots someone else is that the shooter is a criminal who must then prove his or her innocence. While some States provide some legal protection for self-defense, unless you never travel outside the county you live in, those protections cannot be relied on. ‘Stand Your Ground’ should always be viewed as a courtroom strategy not a tactical option. Keep that in mind. Do your best to AVOID or ESCAPE prior to being forced into CONFRONT or RESIST.

Surveillance Detection is a useful skill. Your car mirrors are a tool for you to use frequently, especially at 5AM. It’s beneficial to always take a few turns for Surveillance Detection purposes prior to committing yourself to turning into your driveway or other place you cannot escape from. Once you are Decisively Engaged https://tacticalprofessor.wordpress.com/2014/06/25/situational-awareness-and-positioning-part-i/ because your path is blocked, you are forced to CONFRONT or RESIST.

Note also that “the man was able to retrieve a handgun of his own.” ‘Retrieve’ most likely means that the gun was in the car not on his person. This mention is not intended as commentary about leaving unsecured guns in cars. Rather, it is an observation that many of the incidents in my database involve successfully accessing guns that are stored off-body.

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Purchase of any book includes Serious Mistakes Gunowners Make.

Posted in: Awareness, deadly force, decision making, firearms, Incident Analysis, off body carry, skills, surveillance detection

The Sandra Ochoa Incident (Shooting Analysis II)

By tacticalprofessor on | 2 Comments

In a previous post https://tacticalprofessor.wordpress.com/2021/08/17/the-sandra-ochoa-incident-shooting-analysis/, I discussed Officer A’s shooting performance during the incident. The weapon system manipulation aspects also bear discussion.

This incident forced Officer A to manipulate two different flashlights in rapid succession. He approached the scene with a hand held light, which most industry professionals would consider a best practice. At the gate, he immediately had to make a SHOOT decision and held onto his handheld light while shooting using his weapon mounted light. His shooting grip was compromised as a result. This image capture is from immediately after his sixth shot.

It’s apparent he is holding onto his handheld light with the ring and little fingers of his Support (left) Hand and trying to wrap his index and middle fingers around his pistol. The compromised grip may have been part of the reason for his low hit rate with the first five shots. This observation is not a criticism of Officer A, rather it’s a recognition of the complexity of the manipulation problem he encountered. Having and rapidly using two different types of flashlight in succession is not a training drill we often practice, myself included.

As is often the case, technology has advanced more rapidly than practical doctrine for using it. Several possibilities arise for using the two lights.

  1. Simply do the best you can with what you’ve got, as Officer A was forced to do.
  2. Shoot one handed, while maintaining control of the handheld light in the Support Hand.
  3. Drop the handheld, shoot with the weapon mounted light, and then retrieve the handheld light when necessary or feasible.
  4. Have the handheld on a large flexible ring that allows it to be dropped without losing total control of it. This is the approach I am currently experimenting with.

It’s worth noting that one incident in Real Shootouts of the LAPD involved the use of a flashlight. Also, some of the tragedies referenced in Serious Mistakes Gunowners Make could have been averted by the use of a flashlight. The Ochoa Incident gives us some food for thought about the need for doctrine and practice with flashlights.

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Posted in: firearms, Incident Analysis, practice, skills | Tagged:

The Sandra Ochoa Incident (Shooting Analysis)

By tacticalprofessor on

Body Worn Video (BWV) not only has value for analysis of Use of Force, it also can be used as a shooting analysis tool. By looking at a BWV in conjunction the results of a subsequent investigation, we can arrive at a more complete picture of the shooting incident.

On May 31, 2020, LAPD officers responded to a radio call of a “murder suspect there now.” Upon arrival, the officers observed the suspect cutting the victim’s throat and an Officer-Involved Shooting (OIS) occurred. The BWV of both officers present was later released by the LAPD. The incident was adjudicated by the LAPD Board of Police Commissioners on May 4, 2021. The shooting was ruled objectively reasonable, necessary, and In Policy. https://www.lapdonline.org/assets/pdf/023-20-ois-pr.pdf

A short edited and annotated video of the shooting portion of the incident is available on my YouTube Channel.

Several points can be derived from the BWV and the subsequent investigation and rulings. The first is that there is a significant difference between a shooting and gunfight. Noted firearms authority Ken Hackathorn mentioned years ago that a Private Citizen is just as likely to be involved in a ‘shooting’ as in a ‘gunfight,’ if not more so. In a shooting, there is sufficient cause to use a firearm (deadly force) in defense against an assailant who is armed with a contact weapon or personal weapons (fists, shod feet, etc.). This incident is a good example. The assailant was armed with a pair of scissors and succeeded in murdering her victim with those scissors.

The cadence of shooting by Officer A is another item we can analyze. The LAPD Force Investigation Division quantified the officer’s splits (time between shots) as follows:

  • Shot 2 – 0.340
  • Shot 3 – 0.286
  • Shot 4 – 0.232
  • Shot 5 – 0.247

The average of those splits was 0.276 seconds, with a total time for the first 5 shots of 1.105. The officer was shooting at a cyclic rate for the first five shots. Although he said he ‘assessed’ between those shots, it’s unlikely there was any assessment between shots 1 through 5. Shot number 6 had a split time of 0.711. That’s the more likely point of there being an assessment of bullet damage, i.e., target effect.

Just like Sergeant Tim Gramins in 2013 https://www.police1.com/officer-shootings/articles/why-one-cop-carries-145-rounds-of-ammo-on-the-job-clGBbLYpnqqHxwMq/ , he may have said to himself, “Hey, I need to slow down and aim better.” I.e., shoot better – meaning, achieve an adequate sight picture and perform a smoother trigger press. What likely occurred by the officer was a ‘Bullet damage assessment’ after 5 shots, followed by a marksmanship improvement and a more accurate 6th shot.

Of the 6 shots fired, 2 were hits. There’s no way to say for sure but the likelihood is that of the first 5 shots, 1 was a hit. The 6th shot was likely a hit and perhaps a better hit that got the message across. Viewed this way, there were actually 2 sequences of fire. Sequence 1 consisted of 5 shots resulting in 1 hit, a 20% hit ratio. Sequence 2 consisted of 1 shot, which resulted in 1 hit, a 100% hit ratio.

Nothing in this analysis is intended as a criticism of the officer. Shooting someone who isn’t immediately adjacent to a victim is difficult enough. Shooting with an innocent downrange and right next to the assailant is a very difficult task that is seldom practiced for.

Although the victim in this case died, there’s a good chance she had been fatally wounded prior to the shooting. The officer did the best he could under the circumstances. Not all situations have a Positive Outcome.

Other items of note were that, as is frequently the case, the officer under-estimated the number of shots he fired. There’s nothing uncommon about that. In most of the Categorical Use of Force reports, when more than two shots are fired, the officer undercounts. On the other hand, the officer estimated the distance of the shot quite accurately. He thought it was 20 to 25 feet and the actual distance was 18 feet. Very few people’s eyeballs are calibrated to better than 10% margin of error for distance.

The full LAPD news release video (NRF023-20) is posted on the LAPD YouTube Channel.

Incidents like these, but involving off duty officer incidents, is why I found my work on Real Shootouts of the LAPD https://realshootoutsofthelapd.com/ so worthwhile. The off duty Officer Involved Shootings very much mirrored the thousands of Private Citizen Armed Encountered I have studied. However, there was a great deal more detail available about what led up to the encounter and how it unfolded.

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Posted in: deadly force, decision making, firearms, Incident Analysis, marksmanship

Suspect Held at Gunpoint (temporarily)

By tacticalprofessor on | 12 Comments

https://www.foxnews.com/us/caroline-schollaert-murder-florida-man-charged

Sequence of events

  • Perp establishes Line of Business consisting of checking car door handles for unlocked cars to burglarize
  • Perp finds gun in unlocked car and steals it
    • “The firearm used by the suspect in this murder was found to be stolen from an unlocked vehicle in the same neighborhood just eleven days prior.” –JSO
  • Eleven days later, perp is carrying said stolen pistol while burglarizing the car of a USCG Servicemember
  • Servicemember detects the burglary in progress
  • SM calls 911
  • SM gets own pistol and confronts would-be burglar, ordering him to remain in place until POlice arrive
  • Perp refuses to comply and instead draws stolen pistol
  • Perp fires several shots and hits SM at least once, incapacitating her
  • Perp departs
  • POlice arrive and ‘attend’ to SM
  • SM dies from wounds
  • POlice identify perp
  • Perp turns himself in
  • Family, friends, and fellow SM are heartbroken
  • Perp is charged with murder in the second degree
  • Family, friends, and fellow SM are still heartbroken

Negative Outcome for everyone involved

“Don’t go looking for trouble not expecting to find it.” –John Farnam https://defense-training.https://defense-training.com/present-tense/com/present-tense/

Possible tactical alternatives

  • If you feel compelled to challenge a criminal, do so from a position of cover (concealment does not count as cover). If no cover is available, do not challenge.
  • Use a high intensity flashlight to illuminate and blind the perp before issuing the challenge.
  • If your car door is locked, illuminate the perp with your flashlight from a considerable distance without issuing a challenge.
  • At your own residence, have a large bear-spray type canister of OC close at hand. Spray the perp, without warning, at the maximum range of the container. Be sure to saturate him from the top of his head to the tips of his toes. Then immediately seek cover if you’re not already behind it.
    • “Begin to attrit the enemy at the maximum effective range of your weapons.” –Infantry maxim

Facebook link to Sheriff’s Office Press Conference

https://fb.watch/7l5H9RudgH/

We strongly recommend citizens lock their vehicles and absolutely remove their firearms when exiting. Please do not provide criminals with easy access to a gun that will only be used in more criminal, and as in this case, violent acts.

Jacksonville Sheriff’s Office

Very sad. RIP Airman Schollaert

Posted in: deadly force, decision making, home defense, Incident Analysis, Negative Outcomes, Serious Mistakes

Bloody Violent Battle in Barbershop

By tacticalprofessor on

From the ARMED CITIZEN AUGUST 2021 page of the NRA Official Journals:

On the evening of May 21, a 33-year-old man walked into a barber shop in Riverside, Calif., apparently intent on causing harm. According to the Riverside Police Department, the suspect, an ex-employee, started a fight with a former co-worker. During the fight, the suspect stabbed one of the male barbers, and, when a second employee tried to intervene, he was also stabbed. However, one of the victims was able to retrieve his firearm and shoot the attacker. The suspect was taken to the hospital, where he was pronounced dead by the coroner. The two stabbing victims’ injuries reportedly were not life-threatening and deputies said they considered the shooting to be a case of self-defense. (losangeles.cbslocal.com and pe.com, Riverside, Calif., 5/21/21)

The original story is here.

https://www.pe.com/2021/05/22/man-stabs-2-barbers-in-riverside-before-victim-shoots-him-to-death/

Armed Citizen Task Analysis

  • Retrieve from Storage (handgun)
    • Implied task – avoid menacing others with your handgun as you retrieve it and bring it to bear on the attacker (Rule 2). “Muzzle direction is the primary safety. Always has been and always will be.” –Bill Rogers
    • Implied task – maintain trigger finger in register position until indexed on the attacker (Rule 3). “An Unintentional Discharge during an incident can become a disaster.” –John Farnam
  • Shoot with handgun (Proxemic Distance – Social Space) https://en.wikipedia.org/wiki/Proxemics
  • Shoot in midst of others, some possibly downrange.
  • Implied situational task – don’t send rounds flying out into the parking lot.
    • “One motorist snapped a photo of the shop… A window that had been pierced by a bullet was boarded up.” -Press-Enterprise
  • Implied situational task – don’t send rounds flying into adjacent businesses.
    • “as you can see, we got a grocery store here, some fast food places, other businesses” – POlice spokesman

Here’s a more lurid description of the incident with an “Example of a knife.” Perhaps it’s Jason’s knife.

The Armed Citizen is a good resource for starting a task analysis of incidents from The Real World™.

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Posted in: deadly force, home defense, Incident Analysis

Recognition Primed Decision-making (part I)

By tacticalprofessor on

Recognition Primed Decision-making is a concept developed by Dr. Gary Klein. It has become a widely accepted model for first responders, the military, and in aviation.

The RPD model is based on the idea that experience allows people to make decisions quickly without having to sort through a series of possibilities. Rather, if a situation appears similar to a past experience, the solution that worked in the previous situation can be applied or modified to provide an adequate solution for the current situation.

Since most people have not been mugged, had their home invaded, or been murdered in a previous experience, the relevant question for an Armed Private Citizen is about acquiring the experience. That is to say, ‘How do we train and practice RPD in the absence of experience?’

In order for us to think clearly about self-defense and personal protection, we need to consider ahead of time the types of people and situations we might encounter. Then we consider what our options are, based on our personal preferences and choices. Finally, we can choose ahead of time which option is best suited to deal with the person and situation.

Types of people we might encounter

  • Benign person
  • Angry person
  • Predator or angry person with personal weapons (fists, shod feet, etc.)
  • Angry person or predator with a contact weapon
  • Predator or angry person with a projectile weapons

Examples of situations

  • Area of limited visibility such as a parking deck
  • Walking alone in unfamiliar territory
  • Being in the presence of a person who makes us uncomfortable
  • Having an unknown person approach us
  • Being home in a state of Unawareness or Unfocused on personal protection
  • Etc.

What we want to avoid is the Typical, or at least Common, Self-defense Process.

Model of unsophisticated decision-making by David Blinder

Part II will go into our Options and an interview with Dr. Klein about the model.

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Posted in: decision making, Incident Analysis, Negative Outcomes, planning

Package Deal Update

By tacticalprofessor on

I’m gratified that Thinking Clearly about Self-Defense and Personal Protection has been well received. One reader sent me the following comment, which I found quite gratifying.

I went through the book quickly and my initial impression is that it is superb. Tremendous intellectual effort and incredibly sage and mature counsel on the subject. It’s also incredibly in-depth and thoughtful.

J.T.

I want to spread the word as far as I can so I’ve now included it in the Shooting Drills Package https://www.payloadz.com/go/sip?id=3348053

The Package still includes Serious Mistakes Gunowners Make, also.

I appreciate the loyalty of those who have already purchased the Package, so I will be sending previous purchasers a download link for the book.

Two non-gun related books heavily influenced me in writing the book. The Art of Thinking Clearly by Rolf Dobelli and Small Data: The Tiny Clues That Uncover Huge Trends by Martin Lindstrom are both very insightful books about topics that aren’t often discussed.

Without knowing a proper name for it, I’ve been working with ‘small data’ for decades. I think Lindstrom would have approved of the Deloitte & Touche Real Estate Capital Markets Database that I created years ago. It started out with a few notes in Word and eventually grew into the broadest analysis of Wall Street’s entry into the commercial real estate finance business that has been done. Even the Wall Street soothsayers were only tracking 20 percent of the data in my database.

Contrary to the popular opinion that “the plural of anecdote is not data,” Lindstrom’s work shows that the opposite is actually true. All of Gary Klein’s work about decision-making is based on small data. Concealed Carry Skills and Drills, one of the books in the Package, is based on the concept of small data.

The collection of books in the Package presents a very comprehensive view of using firearms and other tools for preservation of life. Tools, skills, philosophy, and pitfalls are all covered. Those who are serious about our Art will find them useful reading, I am sure. I hope you will consider purchasing the collection.

Posted in: Awareness, concealed carry, deadly force, decision making, firearms, Incident Analysis, Serious Mistakes, The Library

Surveillance Detection

By tacticalprofessor on | 7 Comments

#fridayfundamentals

I had an encounter yesterday with some unpleasant people while grocery shopping. When I got back to my car, they pulled up nearby at a somewhat odd angle in the parking lot. Since I wasn’t sure if they planned to initiate a confrontation, I quickly drove out of the lot.

After such an encounter, it’s prudent to take a Surveillance Detection Route that does not lead directly home afterward. Doing so isn’t particularly difficult but it does require a little thought at the time. You also need to use your rear view and side mirrors regularly during the process. And have a safe place to go if it turns out you are being followed.

First of all, turn out of the parking lot in the opposite direction that you would take to go home. As you drive, look for signalized intersections to turn onto non-arterial through streets. If possible, hit the red light. Sitting at the red light for a minute will allow you to scan the cars behind you without being an inattentive driver. Make at least three turns watching your mirrors after you turn. Contrary to popular opinion, they don’t all have to be Right Turns. Sitting in the Left Turn lane at a signal will frequently give you a better scan of the cars behind you by using your driver’s side mirror than you can get through the rear view mirror. You’ll also have a slightly longer view of the traffic behind you as they turn.

Image courtesy of US Department of State

What you are looking for is vehicles that repeatedly make the same turns as you do. It doesn’t have to be the same vehicle that was involved in the initial encounter. Pairs of people often have two cars and the other vehicle might be the one following you.

Once you go into the Surveillance Detection mode, make a conscious determination you aren’t being followed before you decide to head back in the direction of your home. If you are being followed, don’t go home. Go to a safe place. POlice stations are overrated as safe refuges because they are often unmanned after shift change. Even Atlanta Zone Headquarters in the middle of the afternoon are sometime completely locked up. A woman was murdered in the lobby of an unmanned small town POlice station a few years ago by her estranged husband who was following her.

A better choice is someplace that is usually occupied by some kind of First Responders. Fire stations are one example and hospital Emergency Rooms are another. Even these aren’t fool proof but they are generally a better bet than going to the POlice. Think about several possibilities ahead of time and have them in mind as contingencies if you do need to go into the Surveillance Detection mode.

You could also call 911 but that requires you to able to link up with a patrolling POlice car or go to some place you’re directed to by the dispatcher to wait for help. Waiting for help in a stationary location when you’re being followed is an invitation to disaster. Driving to a safe place is probably a better idea.

Sound your horn even before you get into the safe refuge. Turn on your flashers and, if possible, activate the car alarm. If you have any kind of defensive tool, think ahead about how you might employ it should the situation require. That’s another good reason not to have a pistol stashed under the front seat or some other place it might have shifted around from.

Usually, when someone following you realizes that you are aware they are following, they will break off the pursuit. Don’t count on it though. You want to be prepared to play the game completely to the end. Just because you’re paranoid doesn’t mean they’re NOT out to get you.

On a separate note, a reader of Thinking Clearly about Self-Defense and Personal Protection sent me the following note. It is spot on so I am reproducing it verbatim.

Hi Claude,

You might want to put a notice at the beginning of your book to make sure you have an Internet connection when reading the book, because a lot of the text won’t make sense until the reader reads the article at the hyperlink. And there are a lot of them.

Good thought. Thinking Clearly about Self-Defense and Personal Protection contains numerous references to incidents in The Real World™ to provide context for the concepts in my articles. For copyright reasons, I can’t reproduce the articles in the book, so I link to them. An internet connection will be invaluable for understanding the context behind many of the concepts.

Thanks for the tip. Winner, winner, he receives the complete package of my books with my compliments for his suggestion.

Posted in: Awareness, decision making, Incident Analysis, surveillance detection

Thinking Clearly about Self-Defense and Personal Protection

By tacticalprofessor on

My new book is finished and available on my Payloadz store for download as a PDF.

https://www.payloadz.com/go?id=3377208

Fighting is a ‘game’ of minds.

–Rich Grassi, Editor of The Tactical Wire

Mental preparation for Personal Protection using tools is what the book is all about. Mr. Grassi’s comment encapsulates that concept superbly.

This book is a collection of my articles and essays, some previously published, some unpublished, some published but no longer available. The focus is on the mental processes that lead to achieving Positive Outcomes and avoiding Negative Outcomes. Many of the articles reference actual incidents to provide context from The Real World™ for what would otherwise be hypothetical or theoretical topics.

As alluded to in the title, Self-Defense is only a subset of Personal Protection. Often the person being protected is not ourselves but a loved one, friend, or innocent bystander. While gunowners usually think of a confrontation occurring between themselves and a criminal, the fact is that we are usually around other people. The possibility that another person will probably be peripherally involved and perhaps in danger is high. This simple fact requires serious thought ahead of time because people do unexpected things under stress.

The book is organized into several sections. Each section contains a number of articles that pertain to a topic. In many cases, an article relates to several sections so the most appropriate category was used.

  • Mindset
  • Awareness
  • Know the Rules
  • Decision-making
  • Incident Analysis
  • Negative Outcomes
  • Appendix of shooting drills

No publication can be a definitive work about such a broad subject but my hope is to stimulate thinking about the complexity of the subject from a different perspective than usual. It’s 105 pages of discussion that often gets overlooked when we talk about Personal Protection.

If you would like to purchase a copy for only $7.99, here is the link.

https://www.payloadz.com/go?id=3377208

As with all my books, Serious Mistakes Gunowners Make is included with your purchase.

Posted in: Awareness, decision making, Incident Analysis, Negative Outcomes, Serious Mistakes