Originally Posted by lomapaseo
I sure hope that you can't find anything written to support the above.
lomapaseo,
your hope is justified. I was mistaken. The version of Annex 13 which is in force since 1 November 2001 says, concerning the format of the report, "3. Conclusions. List the findings and causes established in the investigation. The list of causes should include both the immediate and deeper systemic causes"
Originally Posted by lomapaseo
The problem that I have with a finding of Probable cause is that it attracts most of the attention to a single item that quite often does not lend itself to responding to a practical solution.
Yes. I would go further. The problem I have with it is that there are usually multiple causes, and multiple systemic causes, amongst the facts that one has selected as being pertinent. (The selection of pertinent facts is another area which lends itself to manipulation and confirmation biases.)
Originally Posted by lomapaseo
The idea behind investigating in the first place is to determine any holes in the swiss cheese
It may be worth pointing out that Reason's model, which has been around for some twenty years now and has shown its worth, is no longer the latest and greatest. The ATSB, which has used it for a decade, has been concerned about its weaknesses and moved to Andrew Hopkins's Accimaps to explain the Lockhart River accident. Accimaps are very similar to Why-Because Graphs (WBGs), but they summarise the factors (so there are fewer nodes: 20-30 instead of 80-100), and additionally classify into categories reflecting whatever general categories of systemic causes one considers to have been pertinent. There is a paper on my WWW site from December 2005 comparing the two methods on the Glenbrook, NSW rail accident.
PBL