Imagine having a defined process so important that not following it means the potential destruction of a priceless and irreplaceable item. So why would any rational, well-intentioned person deliberately choose not to follow the process? Better yet, why would three intelligent, rational, well-intentioned people choose not to follow the process? Prepare for a shocking, real-world case study where we discuss this exact scenario, the potential causes of pressure these three people felt, and the dangerous environment where it was not safe to speak up. Further, we will use this scenario to highlight the impact of focusing on efficiency over effectiveness. All three people knew the process, but the pressure they felt from management to be efficient in fixing the problem, caused them to solve it ineffectively. Don’t be like this company. Learn to recognize the real root-cause and take action to correct it, before it causes permanent damage to an irreplaceable artifact.