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Old 16th March 2010 | 15:07
  #9 (permalink)  
turbocharged
 
Joined: May 2008
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From: Kettering
"Quote:
Usually that single factor is the action sequence of the crew immediately prior to impact.

This is at the 'who' level. If you were to ask yourself why the Captain made inappropriate control inputs you will identify a number of CFs. You need to get past the actual actions to the systems level failure"


I think that's what I said. I was trying to distinguish between proximal cause and distal, or root, cause. The problem we have now is that 'no single cause' has become a mantra and actually distracts us from looking more closely at what the actors actually did that contributed to failure.

However, we also need to remember that it's not what they did, it's why they did it that is the most important point to understand.
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