ACOVEE:
Sir, with the greatest respect, it seems that you know little about current methodologies for Root Cause Analysis if you make the statement:
fact is that the root cause was the short circuit bypassing the air valve control system
From my reading of this thread, it seems that this was a known fault that was not dealt with. It would therefore lead me to believe that Safety Helmut has it absolutely right when he says that:
This was a failure of management
When the valve opened (or the nut failed) this would have been a first level causal factor.
Although it is a long time since I wore a blue uniform, it also seems clear from the various reports that I read here that BOIs are still failing to identify ‘Root Causes’ in the proper sense of the phrase.
Perhaps it is time to examine the BOI system.