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There seems to be something more fundamental lacking in the engineer's preparedness for their job.   Despite finding a lack of key information in the published instructions on either the biocide or the maintenance manual, they were not deterred in their confidence that this should be a simple task.  They were convinced the task was simple, and the circumstances did nothing to undermine that confidence.  The missing element in this scenario was self-supervision. 

This episode is also available as a blog post: http://hypothesis-discovery.com/2021/06/01/just-in-time-learning-and-supervision/