This chapter opens with Neil Websdale, a criminologist. Websdale once needed eye surgery, and on the day of the procedure, the nurse made a large X over the eye to be operated on. When Websdale inquired about this practice, the nurse recommended he read some stories on airline accidents and surgical errors. Websdale did and realized that in both disciplines, there were simple remedies to common errors, but that finding those remedies meant putting pride aside to review past disasters honestly.

Websdale began to apply the collaborative processes used in other fields to domestic homicide. Looking at a study of Florida’s homicide cases, Websdale realized that, just as with plane crashes, there was very rarely only one causal factor leading to a domestic homicide. Instead, there were several failures along the way, and several missed opportunities where intervention could have saved lives. This led to the establishment of a Fatality Review Team first in Florida and then in other states and countries outside the US. A year after Michelle’s death, a review team was established in Montana, and Michelle’s mother pushed to have Michelle’s case included in the review process.

Despite the widespread adoption of his methods, Websdale admits that some of his views are controversial: “He believes abusers are as stuck as victims.