Tue, Oct 27, 2026Fall (Semester 1) · Week 10Day 35 of 6080-min blockTight fit

Karyotype case analysis

Essential question: How much does the accuracy of a genetic diagnosis depend on the person following the procedure?Enduring understanding: A diagnostic result is only as trustworthy as the standard procedure behind it, so recognizing sources of error is part of reading the result.

Safety gate · before any work

  • Handle scissors with blade pointing down when moving.
  • Keep workspace clear of loose scraps to avoid contaminating another student's karyotype.
  • Wash hands after handling printed lab materials.

Do now

Students individually arrange and interpret a karyotype to identify a chromosomal abnormality in a patient case.

DueTonight, 11:29 PM
Hand in
Completed karyotype template with labeled chromosome pairs, identified abnormality, and one stated procedural limitation.
Where
Turn this in at the drop folder with your district Microsoft sign-in, or hand it to Mr. Mendoza in class. Both count as submitted. Doing the activity in myPLTW does not.

You get two school days for every day you were absent, so this deadline moves with you.

Where you are · this course
Unit 2.2 to 2.3: Chromosomal abnormalities, genetic risk, family evidence, diagnosis from mixed data. Karyotype case analysis ▸ Day 3
Day 35 of 60 this semester25 left before WebXam
🧬 Where you are · PLTW
Principles of Biomedical ScienceUnit 2: Clinical Care ▸ Lesson 2.3 New to the Practice"Problem 2.3.1 A New Patient"
Activity names previewed from public PLTW district curriculum maps for the updated PBS. Mr. Mendoza will confirm the exact numbers in myPLTW once the course shell opens.
Today's driving question

You are handed one patient's scrambled images. Following the SOP, can you arrange all 23 pairs and correctly name the abnormality without introducing your own error?

Today you'll be able to

Students individually arrange and interpret a to identify a chromosomal abnormality in a patient case.

You've got it when
  • Produce a correctly ordered following the lab SOP.
  • Identify the chromosomal abnormality and state one procedural limitation.
Due today · Lab report RequiredCompleted template with labeled pairs, identified abnormality, and one stated procedural limitation.
Do-Now · start these with your notes closed
  1. Name two features you would use to match one to its partner in a .
  2. In this lab, what is the and what is the ?
Do this · step by step
numbered so we can always find our place
  1. 1Record the SOP for cutting, pairing, and ordering images.
  2. 2Identify the independent and dependent variables in this diagnostic procedure.
  3. 3Sort chromosomes by size and centromere position into 22 pairs plus sex chromosomes.
  4. 4Compare the completed to a reference to detect any extra or missing .
  5. 5Name the abnormality and note one source of error that could affect the reading.
Interrupted or lost? Lost your place? You should have the SOP recorded and your variables identified (steps 1-2). If so, keep sorting chromosomes into 22 pairs plus the sex pair (step 3), compare to the reference (step 4), then name the abnormality and one error source (step 5).
The story

What did this day actually feel like?

Karyotype case analysis

LAB This one was individual, not team, and it was fiddly in a way I did not expect. You physically cut out chromosome images and sort them by size and centromere position into 22 pairs plus the sex chromosomes.

Sorting by size sounds easy. It is not, because several pairs are close enough that you are squinting at centromere position to break the tie. I misplaced a pair, which shifted two others, and did not notice until my final count was off. Had to redo about a third of it.

The abnormality in my case was visible once the sort was right, and completely invisible before. Which is the lesson: the diagnostic power is in the procedure, not in the looking.

Turned in: mounted karyotype and abnormality statement, handed to the collection tray → Lab Reports folder

Fiction. There is no such student. The lessons, labs and dates are the real planned course; the student, the classmates and the conversations are invented.

The comic

The same day, drawn.

Drawing, panel 49: Karyotype case analysis.

Sorting by size sounds easy. It is not. I misplaced one pair, which shifted two others, and did not notice until my count came out wrong.

Panel 49Karyotype case analysis · 2026-10-27
Read week 10, 5 panels

Fiction. There is no such student. The lessons, labs and dates are the real planned course; the student, the classmates and the conversations are invented.

🛠 Get unstuck · pick your level

Run the lab
Run the karyotype: pair all chromosomes by size, banding, and centromere, compare to the reference, name the abnormality, and record one specific source of error that could have changed your reading.
Absent? Async catch-up
If you were absent, use the provided completed karyotype image and answer: which chromosome is extra or missing, what abnormality does that indicate, and what error could a technician make while pairing?

Lab day: Tier 1 is the whole class at the bench. No extension today.

🔑 Today's words · 5

karyotypeinheritancegenotypephenotypecarrier
+2 more in the word bank

Tap a word in the lesson for a plain meaning and one example. Recycled into next week's Do-Now.

Today's study notebook
Karyotypes, pedigrees, and the patterns that pass traits from parents to children.
Open the notebook
Watch first: today's 1-minute intro
Audio overviewVideo overviewMind mapStudy guideFlashcardsQuizData table
Where this fits
Tested on (Ohio WebXam)
Principles and Practice of Biomedical Technology · 072110
PLTW lesson
PBS · Lesson 2.3 New to the Practice
WebXam domain
Biotechnology Research and Experiments
Evidence to produce
Lab report
Lab / skill
Printed chromosome image sheet (one per student), Scissors
Do the work · 80-minute blockfirst 5 min = hook

💡 Big idea: A is a diagnostic tool whose result depends on following a precise SOP, so an error in cutting or pairing can produce a false diagnosis.

  1. 0-5 minReview SOP posted at station: cutting, pairing, and mounting sequence.
  2. 5-10 minIdentify and record ( images given) and (completed reading).
  3. 10-50 minIndividual construction: sort 22 autosome pairs plus sex chromosomes; mount on template.
  4. 50-65 minCompare to reference ; identify and name the chromosomal abnormality.
  5. 65-75 minRecord one source of procedural error that could affect the diagnosis.
  6. 75-80 minSubmit completed and written abnormality statement before leaving.
Mr. Mendoza's 5-minute intro
  • Today you are the clinical cytogenetics technician: your reading is what the will use.
  • Follow the SOP exactly, sequence matters just as it does in a real lab.
  • This is a Handling/Preparation/Storage/Disposal skill (WebXam 072110 strand 5): precision and documentation count.
  • When you identify the abnormality, write it down in proper clinical language.
Know by the end
  • Chromosomes are paired by homologs using size, banding pattern, and centromere position.
  • An extra or missing detected in a indicates a numerical abnormality.
  • Procedural errors in cutting, pairing, or image quality can produce a false reading.
Open this PLTW section today

Unit 2.2 to 2.3: Chromosomal abnormalities, genetic risk, family evidence, diagnosis from mixed data. · case analysis

Day 3 of this lesson. Open this exact section in myPLTW (find it in Clever, Microsoft sign-in), then do the work below.

Do this: Open myPLTW and locate the Lesson 2.2 Decoding a Diagnosis activity. Use the platform's reference images to verify your pairing.

Complete

Record your abnormality finding in the platform response field and submit.

How far to get

You finished the chromosomal-abnormalities task Tuesday. Today you should reach the abnormality-identification question and submit it.

Upload as evidence

Completed paper plus platform submission count as your evidence.

The official PLTW activity stays inside myPLTW. If myPLTW will not open, use F1 and E1-E3 on this page to complete today's local evidence decision, then make up the official activity when access returns. Turn this in at the drop folder with your district Microsoft sign-in, or hand it to Mr. Mendoza in class. Both count as submitted. Doing the activity in myPLTW does not.

Today's PLTW tracker · fill in and submit

Check things off as you work, then submit. This tells Mr. Mendoza how you're doing so he can help the class. It does not replace turning in your producible through the submission route shown below.

Use the code Mr. Mendoza gave you, not your name. Saved on this device.

Unit 2.2 to 2.3: Chromosomal abnormalities, genetic risk, family evidence, diagnosis from mixed data.Day 3 of this projectSee the full week plan
Today's PLTW target

Unit 2.2 to 2.3: Chromosomal abnormalities, genetic risk, family evidence, diagnosis from mixed data. · Karyotype case analysis

Open myPLTW and locate the Lesson 2.2 Decoding a Diagnosis activity. Use the platform's reference images to verify your pairing.

You finished the chromosomal-abnormalities task Tuesday. Today you should reach the abnormality-identification question and submit it.

This is how Mr. Mendoza sees the class keeping pace with PLTW. Be honest, it only helps if it is accurate.

1 · What you do today

🎯 Students individually arrange and interpret a to identify a chromosomal abnormality in a patient case.

  • Record the SOP for cutting, pairing, and ordering images.
  • Identify the independent and dependent variables in this diagnostic procedure.
  • Sort chromosomes by size and centromere position into 22 pairs plus sex chromosomes.
  • Compare the completed to a reference to detect any extra or missing .
  • Name the abnormality and note one source of error that could affect the reading.
2 · What you turn in

Lab report: Completed template with labeled pairs, identified abnormality, and one stated procedural limitation.

Turn this in at the drop folder with your district Microsoft sign-in, or hand it to Mr. Mendoza in class. Both count as submitted. Doing the activity in myPLTW does not. Use the checklist just below and upload by 11:29 PM for full credit. Absent with an excused absence? You get two school days for every day you were absent, so this deadline moves with you.

3 · Who's doing what (team)
TaskWho
Record the SOP for cutting, pairing, and ordering images._______
Identify the independent and dependent variables in this diagnostic procedure._______
Sort chromosomes by size and centromere position into 22 pairs plus sex chromosomes._______
Compare the completed to a reference to detect any extra or missing ._______
Name the abnormality and note one source of error that could affect the reading._______

Working solo? Put your own name in "Who" for every row.

4 · Words I can use correctly
5 · I'm successful today when I can…
  • Produce a correctly ordered following the lab SOP.
  • Identify the chromosomal abnormality and state one procedural limitation.
6 · Reflection & next steps
Where are you today?0/7 checked
Pick your period and code first.
Your 4 steps today
  1. 1
    Do this
    Students individually arrange and interpret a karyotype to identify a chromosomal abnormality in a patient case.
  2. 2
  3. 3
    Submit this
    Lab report: Completed karyotype template with labeled chromosome pairs, identified abnormality, and one stated procedural limitation.
  4. 4
    Submit it here
    1. 1Open the drop folder.
    2. 2Sign in with your district Microsoft account, not a personal one.
    3. 3Upload the file, named Lastname_Firstname__Assignment Title.
    4. 4Your own upload panel says Uploaded with a green check: that is your receipt.
    Turn this in at the drop folder with your district Microsoft sign-in, or hand it to Mr. Mendoza in class. Both count as submitted. Doing the activity in myPLTW does not. Principles of Biomedical Technology (Principles of Biomedical Science) › Unit 2.2 to 2.3: Chromosomal abnormalities, genetic risk, family evidence, diagnosis from mixed data. › Lab report
    Open the drop folder
Were you absent? Jump to the make-up plan
Learn it · deck, reading, and vocabulary
Socratic teaching slide deck

The deck carries the prior idea forward, lets you inspect an analogy, maps the rule to biology, and ends with the same evidence decision and exit ticket used on this page.

Generated from this lesson's canonical data with a red-team citation check.

Carry forward

Genetic tests reveal permanent, shared family information, so decisions about testing must be governed by consent and privacy rather than by any single person's wishes.

Daily take-home

A is a diagnostic tool whose result depends on following a precise SOP, so an error in cutting or pairing can produce a false diagnosis.

Inspect the analogy

A smoke alarm detects signs of fire but can also react to burnt toast.

  1. What does the alarm detect?
  2. What creates a false alarm?
  3. What evidence is needed before declaring a fire?
Rule

A screening signal changes what to investigate next; it does not automatically prove the cause.

Where it breaks

Biomedical tests have measured performance and biological sampling limits that a household alarm does not capture.

Map the analogy to biology
  • Alarm signal maps to a test result.
  • Burnt toast maps to a .
  • Inspection maps to confirmation or the next test.
Read this first

Driving question: You are handed one patient's scrambled images. Following the SOP, can you arrange all 23 pairs and correctly name the abnormality without introducing your own error?

What you already know: Genetic tests reveal permanent, shared family information, so decisions about testing must be governed by consent and privacy rather than by any single person's wishes.

New idea: A is a diagnostic tool whose result depends on following a precise SOP, so an error in cutting or pairing can produce a false diagnosis.

Visual or model: F1. F1. A lesson illustration or teaching diagram for Karyotype case analysis. Use it with E1-E3; it is a model or context image, not experimental or patient data. What to notice: Trace the labeled observation or evidence sequence before choosing an explanation.

  1. Observe or measure the relevant feature in case analysis.
  2. Organize the observation with a stable evidence ID.
  3. Apply this rule: A screening signal changes what to investigate next; it does not automatically prove the cause.
  4. Choose the option the evidence supports and state the limit of the conclusion.

Real biomedical example: You are handed one patient's scrambled images. Following the SOP, can you arrange all 23 pairs and correctly name the abnormality without introducing your own error?

What the evidence supports: E1-E3 and F1 support the daily take-home when the response meets the stated success criteria.

What it cannot prove: The package does not support claims beyond this lesson's or any real patient diagnosis.

Vocabulary:
  • : An organized picture of a person's full set of chromosomes arranged by size and shape, used to spot missing, extra, or rearranged chromosomes.
  • inheritance: The passing of genetic traits from parents to offspring through genes carried on chromosomes during reproduction.
  • : The specific set of gene versions an individual carries, which works with the environment to shape observable traits.
  • phenotype: The observable traits of an organism, such as appearance or function, that result from its combined with environmental influences.
  • : A person who carries one copy of a disease without showing symptoms but can pass it to their children.
  • pedigree: A family tree drawn with standard symbols (squares for males, circles for females, filled for affected) so any geneticist can read a family at a glance.
  • : The increased chance of developing a disease that a person inherits because of specific gene variants passed down in their family.

Use it now: Choose one decision option. Cite E1 and E3, then explain how the rule connects the evidence to your choice.

Go further, optional: The source links below are optional enrichment. Every fact required for today's local evidence decision appears in this lesson package.

Evidence set and decision
E1 · Observation

Chromosomes are paired by homologs using size, banding pattern, and centromere position.

Limit: E1 supplies context or an observation; it does not by itself establish the explanation.

E2 · Mechanism

A is a diagnostic tool whose result depends on following a precise SOP, so an error in cutting or pairing can produce a false diagnosis.

Limit: E2 is a teaching statement or comparison and must be checked against the task evidence.

E3 · Result

Produce a correctly ordered following the lab SOP.

Limit: E3 supports only the result or product criterion named here; it cannot justify a broader clinical or causal claim.

PLTW-PBT-2026-10-27 · Simulated classroom evidence scenario

Your role: biomedical investigator

Decision: Your team must decide what the evidence from case analysis supports before submitting the lab report named on the lesson page.

  • Choose the strongest supported explanation.
  • Choose the next evidence to collect.
  • Hold the decision because the evidence is insufficient.

Response: State one choice, cite at least two evidence IDs, explain the rule that connects them, and add one limitation. Submit it as the lab report.

Claim ceiling: The supplied lesson evidence can support an observation, pattern, classroom mechanism, or next-step decision about case analysis. It cannot by itself prove causation, establish a real clinical diagnosis, or justify action outside this classroom task.

Composite case file · PLTW-PBT-2026-10-27

Reason for review: Your team must decide what the evidence from case analysis supports before submitting the lab report named on the lesson page.

Context: A diagnostic result is only as trustworthy as the standard procedure behind it, so recognizing sources of error is part of reading the result.

Timeline:
  • T1: Record the SOP for cutting, pairing, and ordering images.
  • T2: Identify the independent and dependent variables in this diagnostic procedure.
  • T3: Sort chromosomes by size and centromere position into 22 pairs plus sex chromosomes.
  • T4: Compare the completed to a reference to detect any extra or missing .
  • T5: Name the abnormality and note one source of error that could affect the reading.
Evidence records:
  • E1: Chromosomes are paired by homologs using size, banding pattern, and centromere position.
  • E2: A is a diagnostic tool whose result depends on following a precise SOP, so an error in cutting or pairing can produce a false diagnosis.
  • E3: Produce a correctly ordered following the lab SOP.

Measurements: No patient measurement is supplied unless it appears explicitly in E1-E3 or F1. Do not invent a value.

Figure finding: Teaching diagram for case analysis. Trace the labeled observation or evidence sequence before choosing an explanation. This is a teaching model, not patient or experimental data.

Uncertainty: This is a composite classroom scenario. Missing history, measurements, or confirmation tests remain unknown and limit the conclusion.

Design record
Criteria
  • The solution must address the stated need in case analysis.
  • The decision must be supported by E1-E3.
  • The final product must make the success criteria visible.
Constraints
  • Complete the work inside the 80-minute block.
  • Use only supplied or teacher-approved materials and evidence.
  • Do not trade , accessibility, or privacy for speed.
Tradeoff weights
  • and evidence quality: must pass before scoring other criteria.
  • User need and effectiveness: highest scored criterion.
  • Time, cost, and ease of use: compare only after and effectiveness pass.

Test evidence: For each option, record the E1-E3 result that supports or fails each criterion. Do not assign a score without a named observation.

Iteration log
  1. Version or option tested
  2. Criterion met or missed
  3. Evidence ID and result
  4. Revision made
  5. Reason for the revision
Decision record
  1. Need and user
  2. Criteria and constraints
  3. Chosen option and evidence
  4. Test result
  5. Revision and reason
Watch the trap

Students often think Students often think that once a is 'about the right size' it belongs in that pair, so they stop checking after size.. The trap: Size alone is not enough; two chromosomes can be close in length but differ in banding pattern and centromere position. The trap is pairing by size only, which lets a misplaced slip through and produces a false reading.

Worked example · a parallel case (guides, does not reveal)
Completed karyotype and abnormality statement
Completes: A finished karyotype template with chromosome pairs ordered per the SOP, the identified abnormality named, and one stated procedural limitation.

Karyotype lab (Patient A):

  • SOP followed: cut each chromosome image, sort by size (largest to smallest), align by centromere position and banding pattern, place into 22 numbered autosome pairs plus the sex pair.
  • Variables: independent variable is the patient's chromosome images; dependent variable is the final pair count and arrangement.
  • Result: 22 normal autosome pairs and XX, but chromosome 21 has three copies instead of two.
  • Abnormality named: Trisomy 21 (Down syndrome).
  • Procedural limitation: if two chromosomes have similar size and banding, I could mis-pair them, which would produce a false reading; poor image quality makes this worse.
A completed karyotype template with 22 numbered autosome pairs and an XX pair, chromosome 21 shown with three copies and circled as the identified abnormality.
Why this matters

This model shows the level of evidence and organization needed to complete: A finished karyotype template with chromosome pairs ordered per the SOP, the identified abnormality named, and one stated procedural limitation.

Build yours step by step
  1. State the question and method.
  2. Present the observations and data with units.
  3. Explain the result, limitations, and next investigation.
Change it for a new task

Keep the structure. Replace the question, facts, measurements, and evidence. Then recheck units, vocabulary, and whether the conclusion goes beyond the evidence.

Also due today: Turn in the mounted karyotype and the written abnormality statement to the collection tray before the period ends.

See the full worked example
Portal terms
CER:
Claim, Evidence, Reasoning: make a claim, back it with evidence, explain your reasoning.
SOP:
Standard Operating Procedure, the exact steps to follow (especially in a lab).
Tracker:
Your PLTW progress log where you record completed evidence.
myPLTW:
The PLTW course site where you do the online activities. Find it in Clever with your Microsoft sign-in, right next to Schoology.
This unit's vocabulary
/JEE-noh-type//FEE-noh-type//PED-ih-gree/

Tap the speaker to hear a term. Add two of these to your notebook glossary with a definition and an example in your own words.

Build your vocabulary · optional, for extra credit

Pick just 2 or 3 words from today and make them yours: write what each one means in your own words, name the context clue or evidence that helped, then give one example from what you actually did in Karyotype case analysis. Try your own words first; the glossary is there if you get stuck. This is voluntary and counts as extra credit, so keep it short.

karyotype
inheritance
genotype
phenotype
carrier
pedigree

Saved on this device. Show Mr. Mendoza or add these to your notebook glossary to claim the extra credit.

Resources & readings

Hand-picked readings and interactives for this lesson, from authoritative open organizations and PLTW's own public course outline.

Check yourself · commit, then reveal

Claim ceiling for this check: The supplied lesson evidence can support an observation, pattern, classroom mechanism, or next-step decision about case analysis. It cannot by itself prove causation, establish a real clinical diagnosis, or justify action outside this classroom task.

Quick self-check · commit, then reveal

Your finished karyotype shows only one X and no second sex chromosome, giving 45 chromosomes total. Before you report it, what is one procedural error you must rule out?

How sure are you?

Write an answer and pick a confidence to unlock the key.

Cumulative WebXam review · flash practice

Fast retrieval with instant answers, not the commit-then-reveal check above. Try each from memory first: write what you remember about the earlier units, then check yourself here.

Tap an answer to check it · nothing is recorded or graded
[Review: Talk to Your Doc: clinical communication and vital signs] What is the purpose of an experiment measuring blood glucose after a drug or a placebo?
[Review: Clinical Data: reading bloodwork and monitoring chronic disease] A monitoring table shows one glucose value far outside the others in a steady dataset. What is the best first action?
[Review: Decoding a Diagnosis: from DNA to protein] A bacterial transformation produces zero colonies even though the protocol was followed. Which is the most likely cause?
A karyotype shows three copies of chromosome 21. What does this finding indicate?
Go further and get help
Lab · prepare, conduct, complete
1Prepare
Pre-lab pass · clear all six to go to the bench
0/6

I can name the procedure's purpose and the evidence I will record. I can identify each named hazard and the control that reduces it: Handle scissors with blade pointing down when moving. My data table is ready before materials are handled.

Finish the checklist before you handle any material.

Bring / set up
Printed chromosome image sheet (one per student)ScissorsGlue stick or tapeBlank karyotype template sheetColored pencil or pen for labelingReference karyotype chart (posted at station)
Safety · specific to today's hazards
  • Handle scissors with blade pointing down when moving.
  • Keep workspace clear of loose scraps to avoid contaminating another student's karyotype.
  • Wash hands after handling printed lab materials.
Review Lab Safety (rules, PPE, SDS, emergencies) and check your contract + test
2Conduct (Argument-Driven Inquiry)
  1. 1Before materials are handled, identify the purpose, variables or comparison, controls, measurement units, and stop-work condition.
  2. 2Record the SOP for cutting, pairing, and ordering chromosome images.
  3. 3Identify the independent and dependent variables in this diagnostic procedure.
  4. 4Sort chromosomes by size and centromere position into 22 pairs plus sex chromosomes.
  5. 5Compare the completed karyotype to a reference to detect any extra or missing chromosome.
  6. 6Name the abnormality and note one source of error that could affect the reading.
  7. 7Record each result in the prepared table before interpreting it. Mark missing, repeated, or invalid results truthfully.
  8. 8Complete the named cleanup and waste route, remove PPE safely, wash hands when required, and confirm the station is ready for the next group.
Prepare this data table before materials are handled
Trial or sample IDIndependent conditionMeasured result with unitsObservation before interpretationQuality-control note
     
     
     
3Complete
Argue from your evidence, then compare what you predicted to what happened. Error analysis names a specific method limit, never "human error".
You predicted

Before the procedure, predict the result and cite the rule behind the prediction.

What actually happened

After the procedure, compare the result with the prediction and name one limitation or source of uncertainty.

Your lab report is graded on the rubric below, with extra weight on error analysis and method.
Where this leads: careers
What to do if you were absent
If YOU are absent

Today is individual work you can do from home: complete the same target above, then submit your Lab report.

Open the drop folder

Turn this in at the drop folder with your district Microsoft sign-in, or hand it to Mr. Mendoza in class. Both count as submitted. Doing the activity in myPLTW does not.

If MR. MENDOZA is absent

Class still runs. Complete the online activity above (it's self-guided). Need the concept taught without a teacher? Use this authoritative explainer:

NHGRI: how to read a pedigree
Optional extra credit (async)

You've passed Unit 2, so the optional extra-credit track is open. Complete reserved-unit work from home, including virtual labs, for extra credit. Each item shows its correct submission route.

Open the extra-credit track
How this is graded
For: Lab report: Completed karyotype template with labeled chromosome pairs, identified abnormality, and one stated procedural limitation.
  • Complete
    Every required part of the artifact is present, nothing left blank.
  • Accurate
    The science and the data are correct and match the evidence.
  • Scientific reasoning
    You explain your claim with evidence and reasoning (CER), not just an answer.
  • Professional communication
    Clear, organized, labeled, and written the way a clinician or scientist would.
  • Submitted
    Turned in the right way, on the class site or handed to Mr. Mendoza in class, and confirmed. Not in Schoology: that is where the report-card grade appears later.
  • Error analysis and method · counts double
    Name a specific limit of the method and how it moved your result, and compare what you predicted to what happened. "Human error" does not count; say what about the procedure or instrument caused it.