A busy examiner, working on 15-20 other cases, sets a file aside in the “delayed/pending” queue while awaiting information, and a gun is sold and nine people died. A utility transferred responsibility for recordkeeping functions to its distribution business unit, files containing information about pressure and strength tests were not kept current, and an explosion kills eight. Computer files are accidentally deleted from an Airbus plane and three of its four engines shut down, causing a crash that kills four.

What do these seemingly disparate events have in common?