A routine reminder for $410.00 was drafted, approved and sent to an account whose owner had died five days earlier. Received by the owner's daughter. Ostermill was notified by the account manager on 5 August, the day after R. Vaughn had already found it.
Nothing. All four walls held. The draft was correct against every input available to it.
| INSTRUMENT | READING THEN | WHY IT WAS BLIND |
|---|---|---|
| Task success | Pass, semantic and state | The draft was faithful to its input and the letter arrived |
| Unintended action | No crossing | The boundary was not crossed. The boundary did not cover this |
| Override frequency | No override | The reviewer had no reason to override |
| Confidence | 0.94 | The agent was confident and, on its inputs, correct |
R. Vaughn, spot check, 4 August, by recognizing the account name. Fourteen days after the send. She found it the way she would have found it in 2015: she recognized the name, remembered a conversation, and went looking.
Signal exists, not reachable by the system as scoped. Records change, owner outside this project. Never to be recorded as a model defect.
The balance of $410.00 was written off in full on 5 August. No agent in the path, and none could have been: $410 is far above the small-balance floor, which is the whole of what the agent was ever allowed to post alone. R. Vaughn wrote it off by hand, with M. Ellery's approval on the entry. She telephoned the family the same day, before any written word. The written apology followed over M. Ellery's signature, as owner of affected-person outcomes, the line written into the design file before anything went wrong. All contact with the account is held until the family advises, which is what the note asked in the first place. Counsel was not engaged. The affected-person owner was, and this is the day that line existed for.
Margin, M. Ellery: the useful question in the room was not who missed it. It was what would have had to exist for anyone other than Ruth to catch it. We are relying on a person's memory of a customer, and that is a control we cannot hire for and did not budget.
Margin, R. Vaughn: I would have caught this in 2015 too. The difference is that in 2015 I would have caught it before it went out.
CALENDAR · INCIDENT REVIEW, 11 AUG · EXHIBIT INDEX · H · T6 · POSTMORTEM · THE AGENT, REPLAYED