&gt; 11) Actions at the sharp end resolve all ambiguity.<p>&gt; Organizations are ambiguous, often intentionally, about the relationship between
&gt; production targets, efficient use of resources, economy and costs of operations, and
&gt; acceptable risks of low and high consequence accidents. All ambiguity is resolved by
&gt; actions of practitioners at the sharp end of the system. After an accident, practitioner
&gt; actions may be regarded as ‘errors’ or ‘violations’ but these evaluations are heavily
&gt; biased by hindsight and ignore the other driving forces, especially production pressure.