In any team with years of experience on long-term projects, complacency can slowly undermine critical task execution. This month's case study illustrates how group acceptance of a system that lacked design documents then precluded hazard identification and elimination. Further, informal operational processes transformed hidden design flaws into deadly high-energy conditions. A team comfortable with work processes that rely on tribal knowledge and verbal instruction will foster errors of omission and commission. Our objective is to encourage use of every opportunity to identify risks, hazards and other elements that could impact safety and quality. We need to develop designs and processes that meet specifications and mission requirements without compromise in safety. Hazards must be relentlessly evaluated and measured not only for their likelihood, but also for their impact on the mission, should exposure to that hazard occur. We must hold each other accountable for effective and continuous communication through our documented processes. Risk of failures increase when we grow comfortable that a mission is routine, and expensive controls or compliance can be stripped away because "we have done this before." Rigor in following formal process, including reviews, audits and evaluations that identify hazards, is a proven individual and team behavior that increases a system's margin of safety.