Is this the one you refer to?
DECISION TRAPS : THE TEN BARRIERS TO DECISION-MAKING AND HOW TO OVERCOME THEM
by Edward Russo
It does sound good. I'll have to see if I can dig up a copy. Thanks.
However, books like this always bring to mind Niven's Laws numbers 17 and 18:
17) No technique works if it isn't used.
18) Not responsible for advice not taken.
Niven's Laws are great - the rest of them can be found here:
http://www.larryniven.org/stories/nivens_laws_2002.htm
You dont need to read the book. you get it. One of the examples is the O rings in the space shuttle.
They worked 60+ times, so they would always work....
Variations include - I drive drunk all the time and nothing happens- or I crashed but I didn't do much damage.
Conversely, an accident could happen with all procedures being followed properly....
Looks like in this case- the 'other' official detailed maps were not consulted by this loosey goosey crew. But then the question becomes- did the capt have time to clean this part of the boat up? Turnaround agents should be given time or he should have at least been allowed to break the crew up and bring in proven hands- while the others shaped up.
So now we have lost a turnaround guy. Shame.