Tim Cook uses individual cases and analysis of the systems, processes and human factors involved in unrecognised oesophageal intubation to investigate why this tragic occurrence is still a problem around the world. He offers us some tools and advice to prevent unregognised oesophageal intubation from happening in our practice. This session was recorded at the SAS workshop at CODA22 which took place in Melbourne in September 2022. For more information about the CODA Project go to: https://codachange.org/